In medicine today, it is all the fashion to look toward “the next big thing.” Who can argue with this when it attends to the advancement of scientific research or the clinical means to ameliorate human suffering? But when such a fashion turns all heads to the racy runways of managerial consultancy and academically stylish sideshows of this modern secularist era, there is cause for concern. Such concern is especially germane to all of academic psychiatry, notably chairs, and their diverse constituents. Why? Well, because management is really just “psychiatry by other means” (apologies to von Clausewitz ) with principles rarely more substantive than heavily watered-down palliative phrases rifled from the annals of psychodynamics. Most pertinently, psychiatry is at root— etymologically, at least—the science of the soul. If this is our calling, why not then avail deeper insights rather than heed those parvenus of passing fashion and merchants of managerial gloss?
Why not, instead, look to the old wisdom and seek out the Consolations of Philosophy (2)? To this greater end, let us seek a surer moral compass both to chart and to avoid fatal reefs in the shoals of medical leadership. This is found by looking back to a time when character was destiny and the good guys (and those few gals who then had any sway…) could more easily be separated from the bad. Our backward glance is taken, apropos, in the older form of a classical scientific essay (Fr: essai “attempt”), that is, not a fully expository monograph, but a crisp personal reflection awash with candor, irony, and laconic wryness (and footnoted allusions) to make points more pungently than are otherwise seen in the contemporary mode.
The present formulation of the Seven Deadly Sins of academic chairs is offered as an interim product, albeit not of Montaigne’s (3) mordantly meritorious erudition. This may be of interest as leaders, even in psychiatry, are not immune to a variety of human failings. Greater awareness of the basic patterns of such failures is a necessary first diagnostic step. This simple, desultory diagnostic is meant merely to raise the possibility of eventual improvements in the lives of chairs as well as their flocks (faculty, trainees and patients to whom they are to be, senso stricto, stewards of able staff). Ultimately, an elaboration of the seven cardinal virtues of academic chairs is anticipated as a more therapeutic corollary contribution.
More than 1,600 years ago the Greek monastic theologian Evagrius of Pontus (4) drew up a list of wicked human passions. These passions stole people from “proper” love toward egregious self-fixation: gluttony, lust, avarice, sadness, anger, acedia (Gr: “spiritual weariness”), vainglory, and pride. In the late 6th century, Pope Gregory I the Great (5) formalized these as the seven deadly sins (alternatively, the seven cardinal sins or capital vices); Pope Gregory conflated acedia with sadness and vainglory with pride, and then added envy as a new category. Certainly, a leader in any domain might do well to reflect upon and avoid such sins.
This essay, fundamentally nosologic rather than therapeutic, offers a revised roster of the “seven deadly sins” specifically referencing department chairs in psychiatry, but also being more broadly applicable to deans, vice president, president, chancellors, et alia, both as a contribution in itself as well as something of an antidote. As antidote it is meant to mitigate the more secularly bland, banal, and bureaucratic bromides that are so much now in vogue. Such bromides routinely flow from a variety of overarching entities of neo-Aristotelean authority (e.g., centers for Medicare and Medicaid Services, American Association of Medical Schools, Liaison Committee for Medical Education, Accreditation Council for Graduate Medical Education and its Residency Review Committees, Joint Commission for Accreditation of Health Care Organizations, and others of that ilk that in their bureaucratic ethos and with increasing frequency, like Musil’s The Man Without Qualities , mistake precision for accuracy). Today in medicine and psychiatry it is perhaps not often enough recalled that a leader so bold and grand as Julius Caesar (7) deeply worried how often “bad precedents begin as seemingly justifiable measures.”
Be That as It May, the “Seven Deadly Sins” of a Department Chair
1. Personal Inadequacy 2. Technical Incompetence 3. Conceptual Constraint 4. Social Clumsiness 5. Faulty Discernment 6. Passive Acquiescence 7. Flawed Character
As with the original cardinal sins, no human can fully or consistently measure up. Still, failure by a department chair to avoid these “seven deadly sins” inevitably entails some experience with “hell on earth” even as such a “road to perdition” is ever “paved with good intentions.” For a department chair (as well as affiliated faculty, students, residents, and staff) to have hope of salvation and avoidance of damnable suffering, let us consider these cardinal sins more closely.
Personal inadequacy is, quite simply, an insufficient track record. A chair is inauthentic to the extent that he or she has not achieved basic accomplishments in educational attainment, clinical acumen, research productivity, administrative success, and ethical esteem. Most chairs are adequate to the basic tasks. Nevertheless, the peculiarities of institutions and their deans, other academic medical center needs, and the talent available constitute the stage for the ascendancy of inadequate people into roles of leadership (e.g., departmental chairs, deans, et alia) more often than might be preferred in a better world.
When such an inadequate individual rises to a chair, it is to raise this to a Peter Principle range above the ceiling of actual competence. Consequences are bad enough when the incumbent comes to realize the situation—embarrassment, depression, and all manner of shame can ensue. But the consequences are arguably worse when the incumbent remains oblivious to his or her shortcomings. Here, the suffering is foisted on to others, notably faculty who are “led” by someone they neither trust nor respect. As in all health matters, primary prevention is best.
Technical incompetence is an unsound grasp of one’s field. For a chair, avoidance of this sin builds upon the above base of personal adequacy with respect to education, clinical skill, research compendium, administrative experience, and ethical maturity. But, more importantly, it moves beyond that personal realm into the realms of others, including departmental colleagues, staff, trainees, academic medical center peers, university and hospital officers, and ultimately, the larger community beyond.
Moreover, these doings involve important wranglings over resources and institutional priorities wherein departments of psychiatry have a long, tawdry tale to squall as the ever-scrawny runt in the medical-academic litter. Indeed, skill at such resource wranglings—whether with peers in rival departments, not to mention the dean’s office, hospital administrators or manifold other “partners”—is probably the factor least attended to at the time of chair selection, yet it is one of critical and ever-increasing importance. A technically incompetent chair ensconced as head of the complex array of people and problems that compose an academic medical department is analogous to an eagerly sought, yet disappointingly short honeymoon in what is soon to be realized as a star-crossed marriage. Again, primary prevention is best, but there can be strength in numbers (should the chair avail of faculty collegiality).
Conceptual constraint is the limitation (even absence) of either cogent strategic thinking or the corollary tactical skills of persuasion and adroit maneuvering. It has, in the memorable phrase of President George H.W. Bush, to do with “the vision thing.” Clear vision presupposes the fundamental personal adequacy and technical competence considered above, but moves onward to the arena of “leaderly” enterprise. This enterprise is to juggle all manner of strategic strengths and opportunities against tactical weaknesses and threats. But not only is such skill increasingly important, it is also surprisingly less common—and where present, often is less robust—than many in academic medicine may imagine.
Psychiatry demands a conceptual breadth and clear perspective to encompass the immense range of a field that runs from depth psychology to neuroscience and beyond to the higher circles of hermeneutical epistemology. Here it is useful to recall that persons accepted to medical school focus on narrow intellective capacities rather than broader social considerations, including “street smarts.” Optimally, a chair is far-seeing, wise, and welcoming of advice. But a chair with limited cogency of strategic concept and/or apt tactical engagement at best bores his compatriots and at worst emulates the French Minister, Andre Maginot (8), in assiduously preparing to lose new wars while reliant on utterly obsolete plans of battle.
Social clumsiness is a dearth of people skills—that is, an inability to communicate, motivate, and delegate. A deaf ear for useful criticism is a common phenotypic equivalent. Social clumsiness also includes aloofness and arrogance, favoritism or cronyism, betrayal of trust, and a more general insensitivity to the needs of others. Here again, all humans struggle with these multiple interweaving and encroaching impulses. Naturally, everyone prefers to work with comfortable companions and is tempted to nurse the occasional grievance. But a chair must express sincere interest in those who are reliant on the goodly offices of the leader and, further, do so in a manner that advances the department rather than expresses personal animosities.
Happily, most chairs have a modicum of communicational competence. It is, nevertheless, true that some chairs are Delphic, others brassy, some dour, and still others idiosyncratic. Ah well, so it goes. But that aside, the job of managing a department comprised of colleagues dependent upon their leader is best promoted not just with genial words. Optimally, a chair is respected as a diplomat and is one who should expect more often to be warmed by the glory reflected in the accomplishments of others rather than in hot pursuit of personal prestige. Likewise, one may have, but should not “play” favorites. So, too, trust is won with difficulty but is easily lost. Aloofness and arrogance are the stuff of despots, not leaders. Ultimately, sensitivity to morale best elicits the generous spirit that defines a strong community.
Faulty discernment is especially evident in academic chairs who cannot navigate the rocky shores of academia and health care systems with all their rampant, heavily armed native apparatchiks. A common practical sign of faulty discernment among chairs is the inability to identify and cultivate talent. Quite simply, getting the right people into the right places with the right frame of mind is what psychiatry is all about. So, too, academic medical administration is about not losing one’s (financial, accreditational, or other) shirt in the process.
Ideally and most often, a chair can readily separate the wheat from chaff in relation to both people and processes. Yet the chair who suffers from significantly faulty discernment is usually anosognosic to both the fact itself as well as to the consequences, which are usually dire. Bungled recruitments, squandered resources, puzzled and even alarmed colleagues typically result as the department takes on water amid the doldrums of fiscal and scholarly torpor. Worse, the rare chair then regresses, Queeg-like, to count strawberries and fulminate at shadows.
Passive acquiescence is the failure to make key decisions even with imperfect data and little time. It is especially otiose when the chair is ducking difficult issues or attempting to ingratiate himself to others, typically to those higher up in the pecking order. Though it makes little sense to fight every fight, the good chair will rise to the critical occasions. Still, medicine has its share of moral “ambivalists” ranging from the feckless to the malevolent Machiavelles (9). The latter are particularly adept at striking, often with unseen claws, when the iron of change is hot. Such predators often pounce when their prey is isolated and weak. Not surprisingly, sometimes the prey is an unoccupied academic chair (or deanship, etc.). Woe unto the people of a department entering such a not-so “brave new world” (10)!
It is important to avoid selecting self-aggrandizing chairs, but this has been known to occur. Still and rightly, a good chair is “unslothful” in his or her desire to see the proper thing done, even in the face of contrary intents at higher levels. Chairs ought not to be sycophants or wimps and should, on occasion, even rouse some rabble. Yet as the Lives of Saints (11) usually ended in agony, so for the rest of us less sublime souls, equipoise is essential. Thus, self-discipline balanced by courage is a fiducial point of reference to help sustain the precarious lives of chairs.
Flawed character, the sine qua non of the most sinful chairs, springs from a lack of basic moral scruple. This is not to be conflated with mere personal inadequacy or other modifiable flaws considered above, for the good chair should manifest integrity and honor. Most do. But an otherwise capable chair may harbor an Achillean heel of chimeric character and most unpleasant can be the stuff stuck upon the missteps of flawed essence. Moreover, on rare instances such traits, by extension, become those that characterize the reigning culture of the department. Sadly here, quite like the medieval presumptions of droit du seigneur (12), only the chair seems to enjoy the iniquitous liaisons. Primary prevention, here more than ever! Gladly, very few chairs suffer from or transmit the sequelae of truly corrupt character.
In all, this is a worrisome and overly familiar roster of human failings in this not the-best-of-all-possible worlds. Though no Dr. Pangloss (13) is on hand, there is still place for hope. At the least, chairs, faculty, trainees and others perhaps can better reckon the bona fides of a given academic department with reference to these enumerated deadly sins. Of course, if portents are especially ominous one can then walk away to new horizons, Lot-like, and not look back (14). But life and work progress amiably enough if the chair is—as most are—at least reasonably talented and sincere. Moreover, the very meaning and etymology of “faculty” from time out of mind have entailed the ability to perceive and act, notably in the academic setting. That is, chairs need input from faculty to realize their fuller potential (and to mitigate their lesser tendencies). So, as is said of group psychotherapy, most of our departments usually deserve the leadership they have.
But rarely is the chair wholly adept at personal interaction, scientific investigation, clinical care, pedagogical éclat, administrative prestidigitation, and all other manner of effective leadership. If indeed there is a department with a chair so sinless; a chair who, with competent charm, ably steers the ship through storm and tempest while ever serving the interests of the gregarious crew; who, with ease, raises finances and distributes munificent resources among colleagues in manner both fair and considerate; if, as I say, one could identify such a department and such a chair, might they not be together considered one of the Seven Wonders of the World?
Until then, we await a future chronicle of the Cardinal Virtues of Academic Chairs, if only as a very “brief correspondence” or, more likely if at all, a single “case report” (the subject of which is yet to be identified). Still, as ours is a profession that aims to realize human potential while easing social distress, we should make every effort to appreciate that there is an abundance of “good-enough” (15) chairs who help orchestrate our important work.