The purpose of this article is to give a personal—and thus, unlikely to be truly representative—account of the complexity of leadership as chair of an academic department of psychiatry. My credentials to provide this perspective are, at best, modest and are certainly still nascent: I joined the Medical College of Georgia in 2000 as Chair of the Department of Psychiatry, at the time having the dubious distinction of being the youngest current appointment to a department of psychiatry in the United States. I have now just passed the first 5 years of tenure as chair with the support of many colleagues within my institution and with mentorship from several senior colleagues and friends. The observations below reflect the perspective of a "rookie" chair, 5 years in learning. The perspective of other chairs, especially those of long-standing tenure and of larger departments, may be understandably different and, indeed, I would suggest are more likely to be representative of the complexity of this position. Offering first these important caveats and self-disclaimers, I am pleased to provide some observations and reflections on leadership and the chair of psychiatry.

It is unclear to me whether there are distinct or unique attributes which coalesce in the making of a chair of a department of psychiatry. The leadership styles, career paths, and personal attributes of my colleagues who are current chairs of departments of psychiatry appear to me to be diverse and without a clear unifying base, beyond the obvious stated interest in pursuing leadership of a tripartite mission: education, research, and clinical care. Neither is it clear that psychiatrists are any better—or for that matter any worse—as chairs than chairs of other specialty departments. What, then, are the leadership attributes of a chair? The American Association of Medical Colleges has provided a helpful booklet on chairmanship (¹). The leadership qualities debated in that book are general (Appendix 1) and seem equally relevant (but no more so) to psychiatry as they are to any other discipline. They are also consistent with the broader business literature on leadership and on motivation.

Life in an academic health center is indeed challenging. Much has been written on the current demise of academic health centers (²)—erosion of public support for academic (educational and research) missions, fierce competition in the clinical marketplace, and demoralization among the faculty workforce due to the uncertainty of career paths. As an institutional leader, the chair must be knowledgeable and in step with these pressures. It is anticipated that he or she will possess an understanding of national academic health care trends, as well as be the institution’s local authority on national trends in psychiatry. Such a level of mastery across clinical, educational, and research domains at both global (systems), and local (mental health) levels feels to me (at least at this stage of my career) to be a tall order—and it is a constant struggle. I find myself listening to and learning from other chairs at our institution, as well as the president, dean, hospital CEO, and practice plan CEO. In addition, information distilled from national meetings, advisory boards, and from fellow chairs all help to form an overall appreciation of psychiatry’s vision—and thereupon the department’s strategic vision—within this dynamic environment. In this sense, the chair functions as a knowledge conduit. He or she advises institutional leaders of what is happening "on the ground" in psychiatry while simultaneously providing information back to departmental members on emerging issues and decisions that occur at the institutional level. It is sometimes a "fine dance" between explaining to institutional leaders how psychiatry is different and leaving them with the impression that we’re making excuses for psychiatry. Here, as in many instances, it is helpful if the chair can be armed with data and/or information on similar situations at other academic institutions.

A key role of the chair is to be an ambassador for the department. It is the chair’s duty to represent the best interests of the department at the institutional level. What may be less evident to departmental faculty is that not infrequently the chair is challenged to put his or her institutional role above that of the department. Decisions on group finances, allocation of resources, and institutional strategic priorities can—and do—place the chair in conflict between his or her loyalty to the institution and his or her service of psychiatry. It seems appropriate to keep a "score card" on this, especially since the chair that is perceived as having (or worse, having actually) "abandoned" the faculty will likely suffer a similar fate from his or her departmental colleagues at some later time. Moreover, it is a major part of the chair’s mandate—often stated explicitly by faculty—to "hustle" for institutional resources on behalf of his or her faculty.

A less acknowledged, but nevertheless important, informal institutional role of the chair of psychiatry is to provide "curbside counseling" and be a referral access point for other faculty and colleagues with emotional difficulties. The issues of professionalism and confidentiality are paramount here. Additionally, the reputation of the chair as an effective leader may be enhanced or tarnished by the responsiveness of the department’s clinical services to urgent faculty needs. When this goes wrong, it can go badly wrong! Several options are available here—to step in as chair, to engage faculty, and to utilize the talents of clinical faculty. I typically choose the latter two options, thereby leaving myself available as an ongoing support. Working with departmental faculty to have a swift, confidential, and effective response to institutional needs is an important aspect of the chair’s leadership role. It is also an opportunity to promote the skills and professionalism of departmental faculty and of the department at large.

The departmental challenges for the chair’s leadership are substantial and diverse (Appendix 2). By far, the most salient aspect of the chair’s leadership is the good stewardship of departmental finances. I remember (with some trepidation) the advice of a colleague, saying in the orientation meeting for new chairs that "you do not want the dean coming in to fix up your finances." The duty of the chair to keep the finances in order is item #1 on Daniel Winstead’s "Advice for Chairs of Academic Departments of Psychiatry: the ‘Ten Commandments’" in the accompanying article in this issue (³). This may seem less relevant at the beginning of one’s tenure as chair when the buoyancy of the new role and the start-up package may obscure underlying financial deficits within the department. It is critical to get an in-depth appraisal of a department’s finances before accepting a chair position. Finances should be a key topic of discussion with the dean during recruitment of the chair.

Keeping the departmental finances in order is no easy task. From a clinical perspective, psychiatry is a low volume, low margin proposition. Additionally, many of the national, federal, and state efforts to curtail health care spending disproportionately affect mental health services delivery. Academic health centers have also seen a disproportionate rise in acute mental health crisis admissions and in indigent care, prompting institutions to curtail mental health services which are costly and "spill over" to its many other departmental services (especially the emergency room). The federal pay line for research is also at a low ebb. The capacity to promote research careers among junior colleagues is a key concern at present (⁴). There also has been shrinkage in availability of support—both federal and state—for the educational mission. Departmental finances are labile and can be thrown to the winds by unforeseen institutional needs/decisions. The chair’s leadership in fiscal management is critical, as the maxim says "no margin, no mission." However, the chair is in a precarious position here. He or she needs to balance admonishment by institutional leadership for failing to lead the faculty toward financial productivity with risking disillusionment of the faculty because of the perceived misprioritization of finances above the academic mission.

In his article in this issue, Dr. Winstead writes thoughtfully on the expectation of mentorship from the chair (³). This is a key "deliverable." It is also one of the more rewarding aspects of this role. It will help the chair’s role greatly to have national support for developing junior research faculty (⁴, ⁵). The blossoming of talent from within a department seems a skill that many of my peers as senior chairs around the country have excelled in. The growth and productivity of their departments are a testament to this.

The extent to which the chair is visible and appreciated as a leader within his or her state is also another important facet of leadership in this position. There is much to be gained from being "a player" in state developments, even if the intent of request appears at first glance to be extraneous to the department’s core missions. This is a role that alumni and clinical faculty expect of the chair. The chair’s capacity to invoke the support of alumni and clinical faculty is influenced powerfully by their perceptions of the chair as a systems leader within their region. Academic-public liaisons with one state’s public mental health system can be a powerful way to advance the department’s mission.

I have been impressed by the talents of my colleagues as chairs to recruit great faculty. This seems a consummate skill—one that is not merely a function of money and resources (though these sure help!). I have watched chairs initiate and sustain recruitment discussions which can go on unrelentingly for several years until the prospective faculty finally "gives in" and joins the department. Such tenacity and personal commitment seem to me to be an important leadership attribute of a chair. Additionally, the ability when recruiting to blend the academic talents with personal styles of faculty so as to foster a distinct departmental culture seems another, perhaps more subtle, recruitment skill of successful chairs.

Conflict resolution is a less glorious but nevertheless vital aspect of the chair’s leadership. It is one area in which we have perhaps the least training and for which we are often ill-equipped when we become chair (at the exact time when such conflicts often require attention). Dealing with disgruntled faculty is a tricky business. The chair who fails to address this issue can quickly find him/herself in a corner, without institutional support or without faculty support. On the other hand, the chair who is conflict shy will facilitate entrenchment among faculty and a festering of interpersonal frustration. As in many aspects of the chair’s role, it is a delicate balance which the chair must find through intuition, administrative acumen, support, and "learning on the job." The advice of senior chairs can be particularly helpful here.

The department of psychiatry at the Medical College of Georgia has a glorious and very interesting history. The first chair was a major figure in American psychiatry. Successive chairs built a strong department which, like so many departments, transitioned in focus over time from psychodynamic- to biologically-oriented programs. One recent chair expanded the department in the early 1990s to one of the largest and most successful at the Medical College of Georgia. His abrupt and tragic death left a leadership void, ultimately filled by a chairman who was later convicted and jailed for fraud. Not surprisingly then, the department involute, lost its support within the institution and the community, its education programs diminished, and clinical services became virtually moribund (with negotiations to contract out). Additionally, departmental finances were in perpetual deficit.

The department’s main asset was a resilient and productive faculty, who remained loyal to the department and intent to turn it around again. Through their efforts and with renewed support of institutional leadership, they regained the department’s momentum. A major effort focused on enhancing the educational enterprise, thereby attracting strong students and residents into the program. Residents and faculty have rallied behind this approach and greatly enhanced the recruitment process for psychiatry and psychology residents. This last academic year was the fifth consecutive year that the department filled all of its positions in the match. The leadership of the residency training director was pivotal in turning this around. Additionally, the psychiatry residency became one of the American Psychiatric Association’s "Top 10 Club," which consists of programs that have 100% membership in the APA. Also, the department’s psychology residency is now one of only 19 programs nationally to receive a federal funding grant for psychology postgraduate training. This program has grown in size and has developed specialized training tracks. The chief of psychology has shown true leadership here. They have also built on the educational resources locally, including the strong mental health presence, supportive leadership, and excellent facilities at the Veterans Administration Medical Center. Consistent with these educational developments, there has been a revival of interest in psychiatry among medical students at the Medical College of Georgia, with some 45 second-, third-, and fourth-year medical students declaring career interest in psychiatry and a vibrant psychiatry interest group. The leadership of the clerkship director and phase I course director has been key in reigniting interest in psychiatry among our medical students.

There also have been dramatic advances in research activities at the department, initiating increase in funding, manuscript publications, and scholarly presentations. A major initiative has been the department of psychiatry’s joining the Medical College of Georgia Neuroscience Center of Excellence (COE), which represents a major focus of institutional effort and strategic direction. This new relationship has been key in attracting talented researchers to the Medical College of Georgia and to our department. Also, it has been gratifying to recruit talented graduating residents from within the program to become junior faculty—a clear indication of departmental momentum and capacity to offer exciting career opportunities.

Sustaining a viable clinical service is a major challenge for an academic psychiatry department which also must have broad patient access for its teaching mission. With the support of the hospital, the Medical College of Georgia’s department is now the dominant provider of mental health services in Augusta, with regional market share for inpatients jumping from 28% to 60% in fewer than 3 years. This growth, concurrent with fiscal restraint and strategic realignment, enabled us to end a 9-year streak of budget deficits for the department. Our department manager has returned a positive budget to the dean’s office for 4 consecutive years now.

A key administrative resource for us has been to engage state-university collaborations successfully. We established a new single provider status for inpatient care for indigent patients served by Augusta’s public mental health system. Our department was awarded a major contract from the mental health system to serve disturbed teenagers. Our residency training director has established a new residency rotation at the Community Health Center and at a dual diagnosis substance abuse program. The department is assisting Georgia’s Department of Mental Health in its developed research initiatives with the public system, including a grant to evaluate recovery. We also have secured competitive national funding to initiate a peer support service of our Veterans Administration Medical Center. The department also has strengthened its relationships in contracts with the regional jail and prison services, including an innovative jail diversion program for juvenile first offenders. The chief of the child and adolescent division has developed a new contract for our child fellows at the adjacent youth detention center. Additionally, the department has ensured that these contractual relationships also serve as relationship sites for educational experiences for residents and medical students.

We have sought out relationships with other organizations. The Carter Center has been a tremendous support for us and has provided us with many opportunities to participate in state and national debate on mental health issues. We have benefited from the close relationship with the thriving department of psychiatry at Emory School of Medicine, including joint educational and research opportunities.

We also have sought out consultation and support from national leaders. We were fortunate to be recipients of visiting professor awards (from Janssen Pharmaceutica and Pfizer Inc., U.S. Pharmaceuticals Group), which facilitated very helpful consultations from psychiatry chairs from across the nation. Collectively, these external and national perspectives were instructive in our rebuilding. It has been gratifying as chair to see this department get back on its feet and contribute again to psychiatry on a national level.

Undoubtedly, the support and close working relationship with the department manager is a fundamental requirement for effective leadership. The manager brings a complementary skill set, is a close confidant, an extra pair of "eyes and ears," and provides a different perspective on departmental and institutional matters. A challenge within psychiatry is to acquire the combination of administrative skills of an academic manager along with the clinical and business acumen of a mental health administrator. The clinical marketplace in mental health is so complex and different from other clinical services that this skill set is an important ingredient for success, and it is not found in the administrator who has general training and experience in clinical operations. Larger and more complex departments often have different administrative managers for these academic and clinical roles.

The support of the institution’s leadership is another crucial ingredient for success. In many institutions, psychiatry is a relatively small player and, consequently, can command just so much of the attention of the institutional leadership entrusted with managing at a macrosystems level. The extent to which the institution’s leadership appreciates the issues in mental health is very helpful for the chair in advocating on behalf of his or her department. At my own institution, the CEO of the hospital is perhaps my strongest advocate on campus. Indeed, he has stated, "This is as good a turnaround of an academic department as I have seen in 25 years of senior leadership." This support has been very helpful in our rebuilding.

Chairs need data! The ability of the chair to be an effective leader—particularly a forceful proponent for his or her department—is enhanced by the availability of real information. Numbers really matter. Comparative data from similar institutions are useful when negotiating on behalf of the department. Dr. Stuart Munro (⁶) has provided a list of helpful sources of information for the chair in his article in this issue. Being able to articulate available information within a business plan is another skill a chair must acquire.

I have found the mentorship of other chairs to be particularly helpful. Although the catch phrase "when you have seen one academic health center, you have seen one academic health center" rings true, the experience of senior chairs can nevertheless be invaluable. In this manner, leadership is fostered from within. I have also found the mentorship and support of the American Association of Chairs of Departments of Psychiatry (AACDP) to be helpful, particularly in gaining an appreciation of national developments in psychiatry.

Dr. Romano’s "The Battered Chairman Syndrome" is a great read (⁷). As this article describes a kind of "day in the life" of a chair of psychiatry, the challenges are protean, often unanticipated, and invariably professionally stimulating. Principles of leadership from business administration (motivation, financial solvency, strategic thinking, institutional relationships) seem to apply equally well to the role of the chair of the department of psychiatry. The position of chair is simultaneously one of leadership and of learning.

The comments on an earlier version of this manuscript from Daniel Rahn, M.D., President, Medical College of Georgia, and from S. Charles Schulz, M.D., Chairman, Department of Psychiatry, University of Minnesota, were much appreciated.