In 2002, the American Association of Medical Colleges (AAMC) published a three-module monograph on “The Successful Medical School Department Chair.” Each module focuses on a distinct aspect of the career trajectory of a chair: from selection and recruitment (Module 1) to optimal characteristics, responsibilities, and skill sets (Module 2) and performance evaluation (Module 3) (1). A quotation from the AAMC document highlights the generic role of department chairs in American medical schools, as these have evolved over the past three decades:
The role of the department chair in United States medical schools has changed. In the past, chairs often functioned as rulers of sovereign units, chosen for their research abilities and renowned for building powerful and autonomous departments. Today, departments are interdependent, and are interwoven with centers, institutes, and programs. Chairs … must possess managerial, financial, and leadership abilities, along with strong skills in diplomacy. While some of the independent, entrepreneurial character of chairs endures, their role and the requirements for success have changed. … the role of a department chair in the modern medical school has evolved into one of the most complex and challenging positions in academia (1).
The chair must have the support of the leadership of the medical school and teaching hospital while gaining and maintaining the confidence of psychiatry faculty as an effective advocate for their interests. In balancing demands from above and below, the chair in psychiatry functions much like other “middle managers” in corporate America.
Most deans and hospital directors agree that the fundamental agent of change within academic medical centers is at the level of the department chair. The problem is that in many medical centers the dean and the hospital director disagree on the changes that are required. Where there is divided governance, the chair is forced to straddle between competing, and often incompatible, agendas. Psychiatry chairs face a tremendous challenge in addressing the tripartite mission of teaching, research, and patient care while straddling the priorities and corporate focus of the teaching hospital and the academic imperatives of the university and medical school. Deans value psychiatry departments that excel in undergraduate medical student teaching, and they take special pride in departments of psychiatry that are research intensive. Hospital directors are not concerned about undergraduate medical educational requirements, and most teaching hospitals do not benefit from the indirect cost reimbursement from the National Institutes of Health’s (NIH) grants.
Within academic medical centers, psychiatry shares certain characteristics with departments of pediatrics and certain specialties of internal medicine. All of these programs carry a disproportionate share of the teaching, but are least able to support teaching and research through clinical income. In contrast, departments most highly valued by hospital directors (e.g., radiology, anesthesiology, and surgical subspecialties) have been able to generate surplus clinical income that can be used to support education and research, but these departments carry fewer educational responsibilities than internal medicine, psychiatry, and pediatrics and they are generally not research intensive.
This divided governance means that the university and its principal teaching hospital have separate boards of trustees. Even when the university board oversees the governance of the hospital as well as the medical school, there are competing agendas, but usually there are mechanisms in place to bring the goals and missions of the hospital and the medical school closer together. In general, a unified governance structure works better for psychiatry departments (and for the academic mission in general) than divided governance. A challenge to any psychiatry chair is how to position her/his department to optimally address the educational and research goals of the medical school, and how to support the broad clinical service mission of the teaching hospital and faculty practice plan. In the sections that follow, I will highlight specific challenges and opportunities in the three parts of the mission (undergraduate medical education, research and clinical practice), followed by a concluding section on the match between a department chair and her/his department. Two areas common to the mission of an academic psychiatry department are not addressed in this article: graduate medical education and community service. Though residency education may be a higher priority than undergraduate medical education, especially at our most prestigious psychiatry departments, ensuring the quality of medical student education is central to the relationship between the chair and the dean. And though community service is an important public commitment by a psychiatry department, it is often of peripheral interest to the leadership of the hospital and medical school. Most importantly, limitations of space dictate what can and cannot be included in this article.
In many schools, psychiatry has the primary responsibility of teaching the biopsychosocial model of human health and illness. During the first 2 years of medical school, departments of psychiatry need access to teachers across the curriculum, including neuroscience, genetics, and behavioral and psychosocial sciences, and must be able to engage committed clinical teachers for the psychiatry clerkship. In some schools, psychiatry faculty play a major role in mentoring within the problem-based curriculum and/or in integrated teaching of psychosomatic medicine in nonpsychiatry clerkships. In most (if not all) medical schools, the relative support from the school to the department bears little relationship to the educational responsibilities being borne by the department (2, 3). The challenges to the psychiatry chair in meeting the educational responsibilities of the department are manifold. In some schools, the preclinical curriculum is managed by a committee. The department chair is expected to recommend psychiatry faculty to serve on the committee and to provide faculty for teaching in the area under the committee’s jurisdiction (e.g., social and behavioral science). In other schools, the psychiatry department is accountable for organizing and implementing the curriculum. Whether the curriculum is managed by committee or by department, the department head must identify medical student teaching as a high priority. In the absence of resources to incentivize faculty teaching, the chair needs to inculcate a value system which places a high priority on medical student teaching and inspires a commitment to those values. The chair needs to identify the best teachers of the preclinical didactic material from among researchers in the department and through educational collaboration with other departments at the medical school, at the university, and throughout the region. Most departments of psychiatry do not “own” all of the resources necessary to teach the didactic materials across the span of preclinical biological, behavioral and social science relevant to mental health and mental illness.
A major challenge facing psychiatry department chairs for the past 15 years has been the organization of the clerkship. As managed behavioral health care has reduced inpatient lengths of stay, the inpatient experience has become a less valuable training venue for the general medical student. Rethinking the clerkship experience in psychiatry should be the task of a broadly based group of faculty, the clerkship director or directors, and the department chair. Rather than viewing the clerkship primarily as a recruitment tool for the department’s residency training program, the chair needs to lead a process that defines essential clinical experiences for the vast majority of medical students who are not going on to psychiatric residency. Experiences in child psychiatry, substance abuse, geriatrics, and consultation liaison psychiatry should be given greater priority than inpatient psychiatry. Many departments rely upon multiple sites for clerkship education. In this situation, the department chair is challenged to provide students with comparable experiences across sites.
Clerkship education historically has benefited from residents as teachers and mentors and from the efforts of voluntary faculty inpatient-oriented teaching. In many departments, the clerkship director has little authority to ensure a quality education. Through the power of the appointments and promotions process and other forms of recognition (e.g., special citations for teaching, special dinners), the chair should be able to bring her or his moral authority and the implicit support of the medical school to support undergraduate medical education. Historically, many departments of psychiatry have not focused as much attention on undergraduate medical education as on the residency training program. Yet, because of the centrality of medical student education to the reaccreditation of medical schools, the degree to which the chair can focus the department’s energies in this area should have a positive impact on the credibility of the department with the dean’s office. This is one area where a new chair can make a profound difference in a relatively short period of time.
The extraordinary burgeoning of psychiatric research within American medical schools began in the early 1980s; psychiatry rose from 10th place in NIH support in 1984 to second place in 1993. Psychiatry has retained second place since 1993. NIH support for research in psychiatry is heavily concentrated in 10 to 15 departments, but in recent years more departments have become research intensive. Unlike departments of internal medicine and neurology, the NIH gives the majority of its grants to departments of psychiatry that have Ph.Ds as principal investigators (4).
Center grants that integrate clinical and basic research have played a significant role in building research intensity in a number of departments of psychiatry. The research intensity of individual psychiatry departments generally follows the research intensity of the parent medical school because research intensive medical schools have an infrastructure that sustains a broad research enterprise (3). Resources such as sophisticated functional brain imaging technology dedicated to research, as well as programs in human genetics and basic neuroscience, can be critical to basic science and translational clinical research in psychiatry. The presence of a federally funded general clinical research center (GCRC), strong biostatistical and epidemiological support, a strong program in behavioral and social science, and an institutionally based health services research program can help psychiatry departments grow and sustain a broad program of clinical research. The most research intensive medical schools actively support most of these resources. At some of the schools, there is still a tradition of protecting a portion of faculty time for scholarly activity, though departments of internal medicine have been far more effective than departments of psychiatry at protecting faculty time for scholarly activity (5). Five of the top 10 ranked departments of psychiatry, in terms of NIH research support, receive some core academic support that has been historically linked to the public sector in their respective states or have benefited from close linkages with research intensive hospitals run by the Department of Veterans Affairs (3). Psychiatry departments that have been able to become more research intensive than their parent medical schools (based upon relative standing in level of NIH grant support) have focused their research programs outside of the mainstream of depression and schizophrenia (e.g., alcohol and drug abuse, health services research, behavioral medicine, geriatric psychiatry, and child psychiatry) or have been able to secure some support for psychiatric research from the state mental health department (3).
Chairs in research intensive and research nonintensive medical schools face different sets of challenges. Psychiatry chairs at research intensive medical schools are generally selected because of their prior research accomplishments and continuing research potential. The dean and the psychiatry faculty expect the chair to advocate for research resources (as from the state mental health authority, the medical school, and the affiliated teaching hospital), to raise funds from local philanthropy, to foster an environment in which research carries the highest priority, and to enable faculty to achieve their research goals.
One of the prime metrics of a successful chair in these settings is the annual growth of NIH research support. Departmental contributions of faculty and resources to broader institutional and interdisciplinary research programs (such as the GCRC) are highly valued. Though the chair may be expected to continue her or his research productivity, the major tasks are generative: to utilize departmental resources to meet the research requirements of all department faculty.
Psychiatry chairs at research nonintensive schools face a very different set of challenges. In the absence of a strong research infrastructure, it is difficult to compete for NIH grants. Research administration at the medical school or university level often lacks the essential experience to understand the nuances of clinical research in psychiatry (as in Institutional Review Board reviews) or to manage funds from foundations and pharmaceutical companies (e.g., clinical trials). The concept of protected time for faculty scholarly activity is repudiated by demands to maximize clinical productivity. In spite of these barriers, some scholarly activity should be part of the mission of an academic department of psychiatry. Even research nonintensive academic medical centers have access to clinical and community populations that would make them potential collaborative sites for clinical trials and/or genetic research at a more research intensive school. The challenge for the department chair in the research nonintensive setting is to conduct an inventory of potential assets, to motivate faculty interested in collaborative research, and to consider establishing mutually beneficial collaborations with research centers at other schools. There are some examples of successful collaborations of this type (3).
No discussion of the place of research in academic psychiatry can be complete without considering the role of the chair in advancing research training in the psychiatric residency. A recent report from the Institute of Medicine highlights the regulatory, structural, and funding barriers to widening the exposure of residents to psychiatric research (6). In addition to the recommendations in that report, departments of psychiatry should play a more active role in the clinical research training programs funded by NIH in the K30 and other institutional training programs. (There are nearly 60 funded K30 programs at academic medical centers across the country.) For this to happen, the psychiatry chair needs to make it possible for advanced residents to obtain training and to begin their clinical research careers in the department. Led by the chair, psychiatry faculty must play a major role in the institutionally based clinical research training program as teachers and mentors. In addition, as part of the effort to better link the education of psychiatric researchers to institutional resources, the department head should work with the admissions office to help attract some M.D./Ph.D. candidates with research interests relevant to mental health and mental illness.
Finally, it is not possible to create a productive research environment in the 21st century without some capital investment. The major source of investment capital in an academic medical center comes under the purview of the hospital director (e.g., resources to acquire and maintain cutting edge brain imaging tools in CNS research). An effective hospital CEO will want to know the likely return on investment. Will investment in psychiatric research advance the creation of a clinical neuroscience center or other clinical center of excellence? Will investment in psychiatric research advance a relationship with the state public mental health authority that might advance the political goals of the hospital or reduce its problem of uncompensated care for the chronically mentally ill? A wise psychiatry chair will advance institutional goals as a critical component of the case for supporting psychiatric research in the medical center.
In American medical schools and teaching hospitals, academic psychiatry is a relatively recent elaboration. Over the past 50 years, academic psychiatry has moved from isolated practice and teaching in large state hospital facilities to practice patterns, teaching, and research that have brought the field closer to other areas of medicine. Unfortunately, as academic psychiatry has come of age, medical schools and teaching hospitals are facing a broad array of financial pressures that undermine support for their academic mission. The models of clinical operations, cost allocations, and fee structures that serve the requirements of fee-for-service interventional specialists and subspecialists do not work well for psychiatry or for primary care. Primary care programs have probably done a better job in making their case for special subsidies of their clinical practices in academic environments in the context of potential referrals to the tertiary/quarternary care system and in their documentation of the costs of clinical teaching. Psychiatry departments have perhaps not done as well in establishing a case for special subsidy. It has been estimated that the average department of psychiatry collects approximately 50% of its charges for professional services, after deductions for support of the operations of the practice plan, contribution to covering the costs of space and clinical support staff in the department, and the dean’s tax (3). If the department is serving a large Medicaid or medically indigent population, these percentages are substantially less than 50% because of bad debts and allowances.
Projected cuts in federal and state funding of these programs will exacerbate this problem. A mid-career level psychiatrist who is billing on the basis of individual psychotherapy or psychotherapy/medication management for 30 hours of patient care per week for 48 weeks per year is unable to generate even half of her or his total compensation from the department (3).
When tertiary care hospitals budget in usual and customary ways, psychiatric beds are considered a net loss because they are allocated the indirect costs of ancillary services but do not generate much activity for the operating room or radiology suite. When the charges for psychiatry beds at the teaching hospital are similar to the charges on medicine and surgery, it is difficult for the psychiatry program to compete against comparable programs in community hospitals and freestanding psychiatric facilities. Hospital directors argue that if they are obliged to produce a competitive rate for psychiatric bed charges by reducing or eliminating the indirect costs of ancillary services, they will have to adjust the internal cost structures within the hospital that will adversely affect other clinical departments. Moreover, in some settings, in order to secure managed care contracts for tertiary care services, psychiatry departments have been obliged by their medical centers to accept heavily discounted contracts that do not adequately cover the costs of delivering psychiatric care (3). Within faculty practice plans, psychiatry departments usually bear the full burden of practice costs (e.g., clinical practice space and physician extenders). In contrast, departments most valued by hospital directors (e.g., radiology, anesthesiology, and surgical subspecialties) have been able to generate surplus clinical income while carrying few burdens associated with the cost of their practice environment (e.g., the costs of space and physician extenders in the operating room and radiology suite). Given the structural impediments in the practice plan and the hospital, it is a significant challenge for the chair of psychiatry to maintain a balanced budget in the face of the financial sacrifices that are demanded as the price for being part of the medical center.
There is no single strategy that will meet the needs of all (or most) academic departments of psychiatry. At a minimum, if the teaching hospital and the practice plan expect the psychiatry department to accept the reimbursement rates offered by behavioral health carve outs (in order to secure full managed-care contracts for the rest of the health center), then the leadership of the hospital and the faculty practice need to address problems of cost, cost allocation methods, and support structure and/or they need to consider a subsidy to enable the department to remain “whole.” The department needs to be able to seek out and accept patients who choose to self-pay at the point of service for psychiatric care, as they would in the private sector. Charges to the department for these billing and collection services should be substantially less than for services that are processed centrally in the institutional practice plan. The department itself needs to structure its clinical service programs in a cost-effective way. As an alternative to requiring faculty to deliver heavily discounted services in a carve out (or hiring additional nondoctoral level mental health care providers), the medical center might work with the department to develop a network of community-based mental health professionals, for whom the academic medical center would become the contracting agent in discounted fee-for-service and/or capitated contracts.
Together with the leadership of the hospital, the practice plan, and the medical school, the psychiatry chair might want to encourage the development of a behavioral and psychosocial services clinical product line as a distinct operating unit within the academic medical center. The direction of such a program requires the same degree of specialized management expertise and operational authority as any other center of clinical excellence. The management team would be responsible for creating a budget-driven strategic plan for clinical services, securing a state mental health department subsidy for uncompensated care, negotiating new and more favorable managed behavioral health care contracts, and exploring other innovative joint venture opportunities. Within the medical center, the product line management should be responsible for all psychosocial and behavioral medicine services provided to other clinical centers of excellence (e.g., oncology, cardiology/cardiothoracic surgery). Support for these services should come as a line item within these centers, and not on the basis of fee-for-service consultations (the usual form of payment to psychiatry departments for consultation and liaison services). In many medical centers, oncology, cardiovascular, and other centers of excellence have created their own psychosocial and behavioral support teams that are independent of the psychiatry department. This works against the interest of the department.
Within the tripartite mission described in this article, the clinical mission is the most problematic in these times. It is a potential source of distinct conflicts between the chair and each of the following stakeholders: the hospital CEO, the head of the faculty practice plan, the dean, other clinical department chairs, the Department of Mental Health, and faculty in the department of psychiatry. Failure to adequately resolve these conflicts can lead to “burn-out” and dismissal.
Many books have been written on successful leadership and management styles. There is no specific recipe that can be followed through a successful term as chair. One should start with a realistic vision of what can be achieved in a specific setting and secure the buy-in of the dean, the hospital CEO, and the faculty in the department of psychiatry at the earliest stage. Over time, the chair needs to maintain a strong sense of optimism, while having a deep appreciation of the serious problems that could lead to a major crisis. On good days, she or he will feel that they would almost be willing to do the job without compensation. On bad days, he or she will feel that they are not paid enough to suffer the aggravation. In the old days, chairs could manage their departments with a good secretary. That is no longer the case. It is important for the department to have a strong management team that can address each of the missions of the department (education, research, and clinical service). For the system to function well, the faculty and the management team need to be able to communicate effectively in developing plans, in identifying problems, and in charting solutions. Communication is essential to avoid false rumors and paralyzing distrust. Effective communication between the chair, the dean, and the hospital CEO is an essential requirement. Each new chair will quickly learn that the quality of the job correlates highly with the quality of the leadership and character of the people to whom the chair reports. There is no question that the leadership role that the chair plays in psychiatric education, research and clinical services can be tremendously satisfying, yet it is also true that being a chair in these times has much in common with the role of “middle management” in any other corporate structure. In complex organizations, there are multiple levels of middle management between the CEO and COO, on the one hand, and the people most directly involved in producing the product or service. In academic medicine, the chair is middle management between the leadership of the hospital and the faculty and staff that deliver clinical services to patients; the chair is again in the position of middle management between university/medical school administration and the faculty who teach and conduct research. The role of middle management in a typical academic environment is complicated by the fact that faculty are not inclined to be led. In this circumstance, leadership is defined to some extent by powers of persuasion. Where a chair has been vacant for some time, or where there has been a rapid turnover in the position, it is likely that there is not a good match between the position and the faculty and/or between the responsibilities of the department and the resources and/or leadership of the medical school and/or the teaching hospital. The challenge to any new chair appointee will be to define the mission, to help develop the resources, and to foster a work environment in which teaching, research and patient care can thrive. That challenge persists through the term of office; it goes with the territory.