Leadership is not defined by the exercise of power but by the capacity to increase the sense of power among those who are led. The most essential work of the leader is to create more leaders.
What qualities and skills are essential to leaders? The most highly regarded authors on leadership put on the top of the list the skills of listening, communicating, managing tensions, developing and enabling others, using feedback and introspection, and taking risks (2–4). A recent study of the major leadership challenges confronting U.S. medical school deans found that they considered open, candid communication to be the most effective means of addressing their most complex problems (5).
Because of a combination of training and temperament, psychiatrists, compared with all other physician specialists, might particularly excel in these skills. Yet they are not overrepresented in academic medicine’s leadership. How might psychiatrists better parlay these particular strengths to play a more exemplary role? This article frames this challenge and offers a number of strategies.
For academic medicine in general and psychiatry as well, the need for strong leaders has never been clearer. Academic health centers must navigate in the face of a great deal of turmoil, competition, and uncertainty regarding funding sources and shifting priorities. Moreover, the complexities of each of the missions—basic, clinical, translational research, clinical excellence, and several levels of medical education—keep compounding. Not only do department chairs and deans require leadership skills, all physicians have increasingly challenging staff and financial management responsibilities. The public expects physicians to be leaders, especially those working in teaching hospitals.
Given that they are the role models for the next generation and those with the greatest opportunities for influence within their communities, it makes sense to focus particularly on the skills of full-time faculty. Since faculty clearly do not arrive with all of the leadership and professional development skills they will require, medical schools ought to offer them the full range of supports, especially given rising demands on faculty to generate revenues, accelerating competition for grant funding, and the explosions in biomedical knowledge which educators must master (6).
Yet, in contrast to corporate investment in their employees, no academic health center currently has a comprehensive faculty development system (7). Most schools offer some faculty development services and some chairs have implemented their own structures, but too often faculty are left to their own devices with regard to career management and acquiring new skills. Some obtain effective mentoring, but large percentages do not (8).
Another argument for more substantial and centralized faculty development resources is that, with faculty appointments increasingly resembling independent practice in terms of clinical load, these appointments are becoming less attractive to physicians, however much they may prefer an intellectually challenging environment. Over the course of their training, residents are exhibiting diminishing interest in joining the academic life (9). The widening income gap between independent practice and medical school salaries in most specialties may be a factor in that today’s medical school graduates have both higher debt and greater preferences for more free time than did their predecessors (10).
Young persons now can anticipate five or more decades of active professional life. Taking a longer view of their options and health, the younger generations seek a balance between work and life, but they see few examples of this among faculty. Messages that physicians must be “married to medicine” remain prevalent, that is, never needing extended or even episodic time away, especially during their twenties and thirties. The continuing tyranny of the assumption that total immersion is necessary, that it is “either career or family,” interferes with creative exploration of less-than-full-time alternatives. With the rising proportion of women entering the profession, medicine will continue to lose access to an enormous quantity of talent if the traditional full-time model remains the only path to leadership roles.
Another concerning indicator that academic health centers must pay more attention to the supply of faculty and their qualifications as role models comes from a well-designed study of faculty at four U.S. medical schools (11). It found that 20% had significant levels of depressive symptoms, with even higher levels in younger faculty. The greater the faculty’s perception of financial instability at their institution, the greater the levels of work strain, depression, and anxiety reported. Over 20% reported thinking often of early retirement. Even if they do not retire early, Baby Boomer faculty are graying and will soon begin retiring. With many schools under pressure to expand class sizes, will there be a sufficient supply of faculty, especially of those who are academically productive and whom students view as excellent role models?
Academic health centers’ lack of attention to human resources is not only shortsighted, it is expensive. The costs of faculty turnover have been estimated to be 5% of academic health center budgets (not including costs of lost opportunity, lost referrals, overload on other faculty, and reduced productivity and morale). Another study found that the costs of recruiting and training faculty are over 1.5 times the first year’s salary (12). Since individual faculty success, as measured by productivity and retention, is key to organizational success, now, more than ever, protecting this investment makes financial sense.
Leadership and faculty development depend on creating a supportive ecology that enables individuals to reach their professional potential. What can psychiatry do to more actively nurture leadership skills in its practitioners and trainees? And how can psychiatrists capitalize on their talents to steer improvements that would benefit academic medicine in general?
Certainly there are no quick fixes or shortcuts that will “grow” more leaders; a long-term perspective is necessary in this work. Promising avenues include the following:
Recruiting and retaining the best faculty increasingly depend upon creating an environment in which individuals can build satisfying careers without having to choose between personal and professional success. Part-time practice has been shown to be satisfying not only for physicians but also for their patients (13).
In addition to less-than-full-time options, other strategies include opportunities to alternate high-involvement phases with lower involvement and unpaid leave for personal reasons without loss of benefits (14). Departments that can offer flexible off- and on-ramps and less-than-full-time options will likely enjoy a competitive advantage in recruiting and retaining faculty.
Mentoring represents the most tangible bridge to continuing traditions of excellence. Since time available for mentoring is at such a premium, it is critical to assist overworked senior and mid-career faculty to make the most of each opportunity to teach and to mentor. Many senior individuals could use supportive coaching in acquiring competencies in mentoring “across differences,” that is, individuals of a different generation, sex, race, and career stage. For example, if they are labeling the younger generation “uncommitted” for seeking more family time, they will likely not have the desired impact. Senior faculty can learn to avoid such common mistakes, such as undervaluing the younger generation’s perspectives, automatically communicating their version of “reality,” and not giving frequent enough feedback. Building bridges to the next generation means skillfully and courageously reaching across the differences of formative experiences, goals, and expectations, as well as differences of gender and ethnicity. Psychiatrists can bring their clinical strengths of active listening, reflection, and avoiding assumptions to all of their mentoring relationships and perhaps coach their colleagues in these skills as well.
In addition to the traditional one-on-one mentoring relationships, given how stretched mid-career and senior faculty are, departments can facilitate more peer and collaborative group mentoring among junior faculty and trainees (15). Examples of these and other types of mentoring programs and supports are now described in the literature, offering promising new ways to meet the coaching and advising needs of junior faculty and of residents (16).
Given that academic medicine is dependent on the current trainees as the next generation of faculty and leaders, residency programs should be actively encouraging the development of trainees’ academic interests. Programs should also offer trainees targeted assistance and coaching in seeking and negotiating the best possible first job; even if they do not stay within that academic health center or in academics, the trainees will appreciate and remember this assistance and support, which will build loyalty and help recruit others. Residency and fellowship programs should also be offering trainees seminars on the whole range of career development skills, such as self-presentation, goal-setting, interviewing, managing key relationships, and delegation.
Vitality across the professional life cycle depends on developing new skills as new demands present themselves. For instance, despite society’s need for physicians with team skills and despite the interdependent missions of all the components within academic health centers, many physicians lack the motivation or skills necessary to effectively partner with other health care professionals (17). Clearly, new models of mutuality, coalition-building, and “facilitative” leadership based on shared authority and collaboration are needed. Psychiatrists may be especially well-suited to introduce such skill and system improvements.
Academic medicine should make greater use of “succession planning,” whereby administrators take responsibility for “bringing up” and mentoring their successors. Because helping your department plan for when you are not there calls for “checking your ego at the door,” this type of planning is rare. But the process of building a strong management team can have many payoffs in terms of financial stewardship and stability.
Many academic health centers are creating internal leadership development programs, some focused at the senior management level and others on associate professors. Most draw on talent from a nearby business school or other local leadership institute (18). A compilation of extant programs is available from the Association of American Medical Colleges’ Faculty Development and Leadership Programs.
Given the need for academic health centers to have innovative leadership, physicians preparing for leadership roles would benefit greatly from experience outside of medicine, especially in negotiation, analysis, and policy (19).
A staple of leadership development in the corporate world, one-on-one coaching has been shown to increase the capabilities of motivated professionals, particularly in the areas of accomplishing objectives, managing conflicting demands, finding new ways of looking at opportunities, and collaborating. Executive coaching not only helps organizations to develop and retain their best talent but enhances decision-making, accountability, and team performance and stability (20). Though individualized coaching is beginning to be available to leaders in medicine (21), its potential as a resource is still far from being realized, especially for those just stepping into their first administrative role.
With leadership challenges accelerating, it is risky to assume that the “cream” will continue to “rise to the top” ready and skilled for tomorrow’s demanding leadership roles. If psychiatry does not act to ensure the vitality of its leadership pipeline, it risks not attracting and retaining the requisite talent to continue to advance in education, research, and patient care. Moreover, psychiatrists are uniquely suited to lead improvements at their academic health centers that will enhance faculty and leadership development across the board.
In addition to improving faculty development programs at the medical school level, strategies to more proactively develop leadership talent include: flexible career options so that young physicians do not have to choose between an academic career and their family responsibilities; peer and collaborative group mentoring among junior faculty and trainees; supportive coaching of senior faculty to more effectively mentor “across differences”; career development seminars targeted at residents; succession planning; and internal leadership development programs.