I have held multiple academic positions throughout my career, including psychiatry clerkship director and residency program director. I was a program director for 8 years and thought it was the best job in the world. In 2002 I became associate dean for graduate medical education at my institution and have come to believe that this is the best job in the world. I get to blend patient care with teaching, and I work with amazing residents. I also have the opportunity to influence programs as they mature, and, most importantly, on a policy and resource level, I have an impact on the quality of training at my institution. Lest the reader conclude that I am easily satisfied professionally, let me assure that I have held a multitude of positions that were definitely not the best jobs in the world. At a recent Association for Academic Psychiatry (AAP) meeting, I was asked to provide some perspectives from the standpoint of a psychiatrist/educator functioning in an institutional leadership position. My job involves the overall management and oversight of the 29 residency programs at my institution. I am responsible for seeing that programs remain accredited and funded and that residents and fellows are generally happy. My former life as a program director has prepared me (as much as one can be prepared) for this position. What about my training as a psychiatrist? Has this better prepared me for academic middle management than a background in internal medicine or surgery would have? Are psychiatrists better suited to managing people in complex systems? My first impulse was to say that we most certainly are. Much of what I do day-to-day involves understanding (or trying to understand) human behavior and supporting people in stressful situations. However, at least in the graduate medical education realm of institutional leadership, psychiatrists are not overrepresented. Psychiatrists make up 4.5% of U.S. physicians and 6% of Designated Institutional Officials (DIOs—the American Association of Medical Colleges’ category for my position). This is in contrast to general surgeons, who make up 4.2% of physicians, but 13% of DIOs, and internists (including subspecialists) at 17% of physicians and 37% of DIOs (1, 2). As I reflected on the principles that have helped me navigate the institutional terrain, my thoughts fell into four general areas.
Although not unique to middle management positions, responsibility without authority has long been identified as a leading cause of stress. In his classic experiments on learned helplessness, Weiss (3) examined the effects of various psychological factors on the development of stomach ulcers in rats. Using a specially-constructed testing box equipped with a paddle that a rat could operate with its paws, he varied the amount of control the rats had over the amount of shock. Rat #1 could avoid and escape the shock by pressing on a lever, thereby maintaining some measure of control over the situation. Rat #2 (the yoked rat) received a shock when Rat #1 failed to emit an avoidance or escape response. The yoked rat could press the lever all it wanted, but this had no impact on avoiding or escaping the shock. Try as it might, its actions had no direct impact on the outcome. Not surprisingly the yoked rat had a significantly higher occurrence of stomach ulcers. Physicians are no stranger to this conundrum. When it comes to managing patients, we do our most careful evaluation, make a diagnosis, outline the treatment plan, educate our patients on why various aspects of the treatment plan are important, and support them in implementing them. But in the end, it comes down to the patient to decide to comply with medication, quit smoking, exercise, not commit suicide, etc.
I believe leaders and/or administrators at most levels deal with this phenomenon as well. In many institutions, mine included, associate deans have the power of the office (the bully pulpit) but very little supervisory, hiring, or budgetary authority over those whom they oversee. In the mid-1990s I had an eye-opening experience. I was invited to attend a luncheon for chairs of psychiatry departments at a national meeting. I noticed, with some surprise, as I was younger and more naïve back then, that the chairs as a whole were just as stressed, overwhelmed and uncertain about the future as my fellow program directors appeared to be. Most chairs have some amount of authority in their decisions to recruit and place team members in the areas where they can do the best job, but this does not mitigate for them the equal number of factors over which they have no control. As with many unavoidable stresses, recognizing the quandary, normalizing it, and knowing that it is shared ubiquitously does help to mitigate the impact on my everyday professional life. It also has challenged and motivated me to be more creative about ways of encouraging and motivating others. Just like with suicidal patients or recalcitrant residents, I do the best I can at clinical or educational diagnosis and treatment planning, enlist help when needed, and then either turn it over to a higher power or sit back and hope for the best. Although I have not yet succumbed to the temptation, I have often thought about opening academic meetings with the serenity prayer.
Like many educators, my passion for education originated with teachers who inspired me and one-on-one work with learners. As I matured professionally, I became excited about the prospect of having a more far-reaching impact on training psychiatrists. When I became associate dean, my view and long-term goals shifted from a psychiatric to an institutional perspective. Not surprisingly, the number of distractions in the form of more meetings, committees, and crises has increased. Although I still have the privilege and pleasure of working with individual residents, it is on a more limited basis than when I was program director, and I spend more time with program directors and faculty than residents or students. Because of this I find it necessary to stay aware of the long-term view or overall mission, especially when sitting in endless meetings. One of my long-term goals for my school is to have candidates of the highest caliber standing in line to train here. I envision anxious medical students across the country, holding their envelopes on Match Day, wishing, “Please let it be SIU.” With every encounter I have and every decision I make, I ask myself, “Will it get us there?” I am reminded of a story about a visitor who was touring NASA during the heyday of the manned space program. The visitor met various engineers. When he asked them what they were doing, they replied, “We are helping to put a man on the moon.” On his way out he passed a janitor who was sweeping. When the visitor asked the janitor what he was doing there, the janitor replied, “I am helping to put a man on the moon.” Everyone in the program was focused on the mission.
Being an effective team leader has been identified as one of the basic tenants of leadership. Team-building often comes down to the skills of understanding human behavior and motivating and managing change for others. This can be seen as leadership or manipulation, depending on your perspective. At the associate dean’s level, this sometimes translates to “how to encourage people to do what I want them to do when I have no direct supervisory or budgetary authority over them.” The ability to keep your eye on the mission or the long-term goal and communicate that to others is clearly helpful in this regard. Not surprisingly, I have found that all program directors and chairs want to have good strong programs and train outstanding physicians and appreciate recognition for this. The challenges mainly come in the areas of resource allocation, regulatory requirements that are not seen as useful or sensible, or in addressing resident concerns that have been brought to me because they were not resolved at the program level. When I have been successful at encouraging people to do what I perceive to be the right thing, it is generally for one of four reasons. In the best scenarios, we agree on a common goal and are working toward the same endpoint. If that is not the case, some will be encouraged to work together out of respect for my office or position. Others may be motivated by respect for me personally. That is one advantage of having been at the same institution for a number of years. With others, it is very difficult to reach a common ground and it is necessary to find some leverage of resources or enlist help.
I believe having a basic understanding of how systems work and common defense mechanisms has been helpful for me in understanding human behavior and approaching team members in the most appropriate manner. Understanding displacement and passive aggression have come in most handy. I am reminded every day of the importance of communication and the potential disparities between what you intend to say and what your audience hears. This is illustrated by a speech I watched given by Paul Tsongas in the 1992 Democratic presidential primary. Tsongas was a soft-spoken, serious individual who was much more likely to expound on policy details than rhetoric in his speeches. During a televised speech on one of his proposed policies, he was interrupted by a loud and angry heckler who berated him, ending his tirade with a challenging “What do you think of that?!” After a brief silence Tsongas responded, “I think I was not as eloquent as I had hoped to be in explaining my position,” and went on to restate his point. Sometimes you just have to keep explaining your position in different ways and in multiple forums and hope that you are as eloquent or as passionate as you need to be.
As mental health professionals, we are all aware of the importance of balance in our personal and professional lives. In the medical community itself, balance is becoming more openly valued and promoted. Although it has always been important, I have found the quest for balance to be even more important and more challenging since I have become an associate dean. Part of this is, I believe, a developmental phase. As we grow older, our lives tend to be more complicated with increasing responsibilities, relationships, children, aging parents, and a world that is generally faster paced. Additionally, the structured time demands of the job are greater. It requires more self-control on my part to leave at a reasonable hour at the end of the day, secure in the knowledge that the work will all be waiting for me when I return the next day. I have learned, as well, that as an associate dean (and I suspect this is no different for chairs, deans, etc.) the decisions I make and the actions I take in the course of my job affect more people than the decisions I made as program director. This does not make them any more important, but it does often make them more far-reaching. If they are popular decisions, the potential is there to have a greater number of people pleased with me. If they are unpopular decisions, the potential is there to have a greater number of people displeased with me. I need to work to keep this in perspective. The opportunities and temptations to obsess over the job are more plentiful than when I was program director or clerkship director. There are fewer individuals supervising me, giving me feedback or providing me with built-in reality checks. For this reason I have found it is even more important for me to be aware of the need to curb this temptation and take active steps to keep the necessary balance.
I do not really know if being a psychiatrist has made me a better associate dean. I know that the mentoring and acquisition of leadership skills I have available through my involvement in the American Association of Directors of Psychiatric Residency Training (AADPRT) and AAP have been helpful. I have to assume that these aids are available in some measure in other specialty organizations. I know that the thoughts and priorities I have outlined in the previous pages draw heavily on psychological principles and basic constructs of human behavior. Clearly my interest in the human condition is one of the things that drew me to psychiatry in the first place. However, when I reflect on where I learned the things I am writing about, outside of personal experience, most of it was from readings and presentations from the business or systems literature rather than the psychiatric literature. Whatever the source, I have found that enjoying and understanding people are perhaps not sufficient, but definitely necessary prerequisite skills for this job. And it is indeed the best job in the world.