What does the Dean of Student Affairs at a medical school actually do, and what qualities does it take to be successful? Medical students, residents, and faculty interested in a career in medical education that includes advising trainees are likely to consider the position of Clerkship Director or Residency Training Director as the prototype for such careers. The position of Student Affairs Dean in a medical school is another option for those interested in medical-education careers. This subject has scarcely been written about (1–3), yet psychiatrists are overrepresented in this position (4). This article is intended to give academic psychiatrists an “inside view” of the job.
The Dean of Student Affairs guides students through medical school, often oversees career and academic counseling, and is charged with the well-being of the students. To accomplish these goals, the Student Affairs Dean interacts with multiple stakeholders in a school, including the Dean of the School, students, faculty, and ancillary offices, to ensure that students are successful. The multifaceted role of the Student Affairs Dean requires understanding how physician identity is formed; the myriad challenges of being a medical student, including barriers to learning, such as depression, anxiety, substance abuse, and learning disabilities; and awareness of the expectations of “millennial” and “Generation-X” students. Facility in working with complex systems is also useful.
Since the end-goal of medical school is to match well-trained physicians to residency, or, if desired, to a position as a physician in an alternative field, the Student Affairs Dean is charged with ensuring the success of this endeavor. Academic and career advising is central to this mission. Advising, in many schools, occurs through structured programs termed “Advisory Dean,” “Learning Community,” or “College” programs, which are usually embedded within the Office of Student Affairs. The nomenclature varies, but the goals are relatively common. This growing trend of “advising programs” is designed to provide 1) a structured environment for students to form a relationship with a faculty member/mentor; 2) exposure to career opportunities and assistance with residency decisions; 3) opportunities to learn about humanism and professionalism; and 4) a forum to discuss curriculum and the school environment with a group of peers. Some programs have developed around themes where students join on the basis of common interests, whereas others randomly assign students to a society or dean with whom they “partner” for their time at medical school. Some programs are specifically geared to career-advising and helping students structure their career plans and their fourth-year curriculum. Others, such as learning communities, may have dedicated space for the group to gather, and career-advising and core-teaching both occurring within the group (5–9). To understand the role of advising within the role of the Student Affairs Dean, it is vital to understand the stakeholders in a medical school and the culture of the students.
Stakeholders are plentiful in a medical school, each with a particular set of expectations that must be addressed by the Student Affairs Dean. They include the Dean of the school and other members of the Dean’s Office; students, both collectively and individually; faculty working directly with students; other offices in the medical school, such as housing, financial aid, internet technology, facilities, preclinical and clinical departments, general counsel; and the Student Affairs Dean himself/herself.
Broadly speaking, the Dean of the school wants the students to be happy, and to perform well academically, particularly on standardized exams, the Match, and other national measures of a school. The Dean hopes that students evaluate the school favorably and often relies on the Student Affairs Dean to address and remediate any dissatisfaction. The Dean expects the Student Affairs Dean to attend to all matters relating to students and to prepare and apprise him of upcoming events and current issues so that he is well prepared for his own role in attending to these. His vision for the school as it relates to the students is, in part, entrusted to the Student Affairs Dean.
To understand the expectations of students requires familiarity with the culture of Generation-X and the Millenials. Both have a different frame of reference than the Baby-Boomer faculty teaching them. They value loyalty to friends, expect balance in their lives, want autonomy—yet guidance, and demand rapid administrative responsiveness (10). Millennials grew up with the vast expansion of the Internet, and they expect ease of access to communication (11). They often were highly scheduled in their activities, rewarded just for participation on the team; they received special treatment when scheduling conflicts arose at school, and had “helicopter parents,” who hovered, and were overly protective and involved (10, 12). These experiences, for some, translate, in medical school, into expectations for readily-accessible and prompt communication, accommodation of special requests, and personalized guidance and advising. These expectations are sometimes at odds with those of senior faculty, who trained in a much more hierarchical and deferential medical culture.
Although students also wish for success of the school, their foremost goal is their own individual success. They expect the Student Affairs Dean to provide the necessary information and advocacy for their individual and collective success and well-being. This is a complex expectation, as it is infused with aspects of the real and transference relationship between student and dean. The Dean is held accountable by some students for shortcomings of the school that are not under the purview of student affairs. The real relationship includes data-driven expectations of the Dean; for example, serving as the source of factual information and directing students to resources such as faculty mentors and research opportunities. The transference relationship includes those parts projected by the student onto the Dean that come from early, important relationships, such as those with a parent. The judging, punitive fears students have of the Dean are a component of this.
The role of student advocate is an important component of the student-affairs position. Students come to the student-affairs Dean needing academic, psychological, medical, and personal consultation. Students seek information, a listening ear, an opinion, approval. They contact the Student Affairs Dean to discuss their interest in a research experience, a year off for dual-degree, concern about academic difficulty, a proposal for a new service organization or social activity, or concern about a family member or classmate. Although the Student Affairs Dean will often designate others on staff to handle many of these inquiries, these multiple aspects of student life are under her aegis, and inquiries are often directed to her. Student Affairs Deans in this regard are facilitators responding to each request, helping students make sound decisions, and achieve their immediate and longer-term goals.
In contrast with the role of advocate is that of authoritarian. Students may be called in by the Student Affairs Dean because of academic difficulty, failure, or unprofessional behavior. For each student, the Student Affairs Dean must listen carefully and determine the best response. Support and activation of resources, such as a psychiatric evaluation for depression, a tutor or neuropsychological testing for repeated academic failure, or a tough stance with strict limits for the student who has exhibited unprofessional behavior may be best. Although students may be fearful when called in, students are very grateful when resolution such as improved academic performance or abated stress follows.
Some students, at least initially, fear the Student Affairs Dean and project onto her their own feelings of self-judgment and fear of failure. One student reported in a survey the “beady eyes” of the Student Affairs Dean judging him when they met after his academic difficulty in a clerkship. In the same survey, students who wrote favorable comments sometimes added that they were pleasantly surprised to find the Student Affairs Dean so supportive or nonjudgmental. In another example of this transference, a student returning to medical school after a leave of absence revealed an anxiety dream of failing his first exam, and reported to the Student Affairs Dean, “the rest of the dream consisted of me, in a panic, trying to get in touch with you to state my case, so I didn't have to start over.” Although Student Affairs Deans indeed have the power to make some decisions, most decisions about a student’s academic progress are in fact made by a faculty committee on which the Student Affairs Deans is a non-voting, ex-officio member.
Faculty members, another stakeholder, are crucial allies for the Student Affairs Dean. As the flag-bearers of education and curriculum standards, they expect the Student Affairs Dean to uphold academic standards for the school, track and address students identified to have academic difficulty, and ensure that the academic mission is maintained. Good relationships with faculty are essential, because the Student Affairs Dean mediates both sides of the faculty–student relationship. The Student Affairs Dean is the “eyes and ears” of the school, tracking the course of performance for each student and noting problems to bring to the attention of the faculty committee. The Student Affairs Dean may convey bidirectionally to faculty and student the concerns, responses, and reports from the other, and mediate differences. When faculty are frustrated that students do not attend a lecture and instead watch a video of the lecture from home, the Student Affairs Dean might refer the faculty member to literature about the Millennial generation and their learning style. Conversely, when students assume that the rules of college apply to medical school and expect an extension for a late paper or write-up, the Student Affairs Dean might further explain the culture of medicine, high standards of professionalism, and the great importance placed on meeting deadlines. When research faculty are angry that a student turned down a summer research fellowship to pursue an opportunity abroad in global health, the Student Affairs Dean reminds the faculty that both areas are important to the future of medicine.
Student Affairs Deans work with faculty representing all the departments and rely on the advice from each department for students to be successful in their endeavors, including the Match. From a transference point of view, although the Student Affairs Dean relies on the faculty, students expect the Dean to be “all-knowing” when it comes to career-advising and the Match. Sometimes, it is faculty who are delinquent in meeting their responsibilities. When faculty do not follow through on tasks such as completing an evaluation form or writing the letter of recommendation they promised, the student may seek the intervention of the Student Affairs Dean. The Student Affairs Dean is sometimes in the middle of disputes between faculty and students and must facilitate communication and resolution between the two parties. This is particularly an issue when students allege mistreatment by residents or faculty, and the department is reluctant to investigate.
Challenging situations arise when students are not compliant within one of the liaison offices, and the Student Affairs Dean is seen as the one with leverage to make the student compliant; for example, with late tuition bills or required vaccinations. The Student Affairs Dean may be contacted to assist in getting the student to respond appropriately. Conversely, when these other offices do not function effectively, students often complain to the Student Affairs Dean, who has access to but no authority over the offending office. Limitations of authority can make such interactions frustrating if the other office does not respond, particularly since the Student Affairs Dean is seen as responsible for the happiness of the students.
Self-expectations from the Student Affairs Dean herself are, of course, quite variable, and the rewards come in many different forms. A mentoring moment, student anxiety transformed into hope and pride, a problem resolved, newfound success—each of these encounters with students brings reward to the Student Affairs Dean. One must love participating in the development of young adults and value medicine deeply to withstand the heavy workload of the job. Yet the act of reciting the name of each graduate at commencement, and knowing the road, often arduous, they each took to arrive at that moment is a deeply moving experience. The generative nature of the position is quite gratifying, as hundreds of medical students are shaped under the influence of a large team that is led by, or at least includes, the Student Affairs Dean. Another form of gratification comes from the wide variety of relationships cultivated by the Student Affairs Dean across all specialties. For those Deans who themselves enjoyed rotating through many specialties in medical school, connecting with each field through the students and faculty brings back positive memories of medical school. One caveat is operative, however. The portion of the dean’s medical identity that comes from working within her own specialty is limited by time. Attention must be given to maintain ties with her department, as the Student Affairs Office represents all departments and is usually physically located in another part of the medical center. Another caveat for the position is the seduction of transference, because the power of the Dean’s position and the characteristics projected by students onto the Dean, both positive and negative, can be deceptive. Faculty and students alike are more likely to publicly agree and less likely to disagree with the Student Affairs Dean because of the power—both real and imagined—of the position, and this can lead to a false sense of power and entitlement in the Dean. Awareness of this dynamic is important for the Dean in order to maintain perspective.
Career-Advising and Medical Student Performance Evaluation (MSPE)
Career-advising and the Medical Student Performance Evaluation (formerly “Dean’s Letter”) form a major backbone of the Student Affairs Dean’s position. This time-intensive role is ultimately quite public, as the residency Match results become a report-card on the Student Affairs Dean, who is either credited or criticized by all stakeholders for the results for the year. Although the results of the Match, in fact, stem from each student’s individual performance throughout medical school, and, especially, in the clinical setting, and the guidance and support provided from Student Affairs and the faculty members involved, the Student Affairs Dean is held accountable. Students enter medical school hoping to pursue their career dreams, which are further shaped by their interests and actual performance in medical school. They may consider the Student Affairs Dean the gatekeeper who will determine their future, when it is actually determined by the competitiveness of their application and specialty. Managing these expectations is challenging. The appropriate balance of encouragement and realism needed by students from the Student Affairs Dean is delicate, and the landscape is ever-shifting. Students request much on-going advice throughout the residency application and match process, and they expect very rapid feedback. Questions regarding which programs to which to apply, what to say in the personal statement, how many interviews to expect, how to manage a low number of interviews, whether to take a second look at programs, how to address the dance of post-interview contact are only a sample of the myriad questions and issues that arise and culminate on Match Day. Since students are sometimes concerned that the Student Affairs Dean will be negatively biased when writing the MSPE if she is also aware of academic or personal difficulties of the student, in some schools, these roles are separated, and another dean, for example the Medical Education Dean, writes the MSPE.
Ceremonies and the Public Face of the School
The ceremonial responsibilities of the job are plentiful, ranging, in many schools, from the White Coat Ceremony, marking the beginning of medical school, to commencement at the culmination, and peppered with other ceremonies and milestones in between. At these events, the Student Affairs Dean is an emissary of the school, who students introduce to their families as “my dean.” The ceremonies mark the seasons of an academic year and the growth of a class of students, and provide a public relations opportunity for the Student Affairs Dean to communicate to the public about the school and students. These are joyful events that are well suited to many Student Affairs Deans because they tend to be extroverted people with well-developed communication skills.
Student Affairs Deans deliver bad news. They contact students about failed exams and boards, disciplinary actions, termination of matriculation, and, rarely, even about the death of a faculty member or classmate, or a catastrophe such as on 9/11. They must be capable of saying “No” to the student who has missed deadlines or acted unprofessionally, and be unswayed by those who avoid taking responsibility for their actions. They must uphold standards for the school and be comfortable setting limits.
Mental Health and Learning Expert
Many of the issues for students truly struggling academically are psychiatric. Occasionally, poor performance derives from previously-undetected learning disabilities or issues. Depression and anxiety are quite common, manifesting in failed exams, missed deadlines for papers and write-ups, showing up late or not showing up for class or rounds, or lack of participation in discussions and activities (13, 14). Although the medical school has administrative psychiatrists and treating psychiatrists and psychologists to provide mental health evaluation and treatment, the Student Affairs Dean must be aware of the frequency of mental health issues and their usual presentations. Since stigma deters students from seeking mental health treatment, the Student Affairs Dean must be comfortable enough with mental health issues to facilitate referrals.
Psychiatrists are well suited to be Student Affairs Deans and are overrepresented in their ranks (4). The communications skills and facility with group-process that are well-honed in psychiatric training are key tools for the job. Psychiatrists are especially able to listen to nuanced communications, verbal and non-verbal, to be non-judgmental, to tolerate negative affect in others, and to set limits. Their background in child and adult development and sensitivity to the shame and humiliation still inherent in medical training help them guide students through the gritty and tough times. Other specialists can certainly develop these skills as well. Former program directors are also especially skilled for the Student Affairs Dean position. They understand the end-game of medical school quite well, (i.e. matching into a residency program), and know the details of the residency application and selection processes. Although program directors set and evaluate curriculum and Student Affairs Deans do not, they are also accustomed to working with groups of trainees, setting limits, and addressing disciplinary issues. Personal attributes that are useful include a high level of executive-function capability, including strong organizational skills and the ability to prioritize multiple demands on a daily basis; ability to set limits, say “No” and deliver bad news; ability to delegate work to others; strong interpersonal and communication skills, and pleasure in serving as the “face” of the school.
The role of the Student Affairs Dean is complex, with competing interests and differing needs from each stakeholder group that interacts with her. She must understand what each expects from her role and help each to understand the perspective of other stakeholders.
The different expectations and learning styles of the current generation of medical students, as compared with faculty, need to be explicated to faculty by the Student Affairs Dean.
Since the Student Affairs Dean holds the individual and collective pieces of student performance, whereas each faculty member only sees his own piece, communication between the two reduces distorted views.
Residency advising involves the Student Affairs Dean and faculty in the specialty, and sometimes advisory deans. Coordination among the parties is helpful to students.
Psychiatrists are particularly well trained in some of the skills that are useful for the role of Student Affairs Dean.
The Student Affairs Dean works in the medical school and thus risks reduction of her professional specialty identity, in contrast with the Clerkship or Residency Training Director, who remain housed in their Department and immersed in teaching their specialty.
The Student Affairs Dean position is a demanding and consuming one that is not for the faint-hearted. The complexity of systems involved—with their multiple demands and stakeholders—calls for a substantial knowledge-base as a medical educator and sophisticated organizational and mentoring skills in the Student Affairs Dean. All the stakeholders have expectations that must be managed so they are realistically aligned with what is feasible and needed and are well served to be aware of competing perspectives. The greatest challenge for the Student Affairs Dean is to coordinate and facilitate the work of the stakeholders without doing their jobs for them or fostering conflict. The wide variety and vast array of issues and problems that must be attended to, however, keep the Student Affairs Dean engaged, challenged, and gratified.