J Thorac Cardiovasc Surg 2001;121:S19-S24
© 2001 The American Association for Thoracic Surgery
Developing the Academic Surgeon: A Symposium |
Becoming a division chief
Edward D. Verrier, MD
From the Department of Surgery, University of Washington, Seattle, Wash.
Address for reprints: Edward. D. Verrier, MD, University of Washington, Box 356310, 1959 NE Pacific St, Seattle, WA 98195-6310 (E-mail: edver{at}u.washington.edu).
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Abstract
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Leading a division or department of cardiothoracic surgery is both a tremendous honor and a significant responsibility. Key to such a position of leadership are committed, functional, and loyal teams focused on the end points of success, and the ability of the leader to develop a strategic vision and to implement a functional operating system.
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Introduction
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Achieving the position of division chief of a cardiothoracic training program in the United States is like many things in life—both a tremendous honor and a demanding responsibility. Although many of the financial resources available to run a division in earlier eras have diminished, and administrative demands have increased, the rewards are great, but you must honestly understand early what you are getting yourself into. For those of us committed to academia, the balance of resident education, the academic pursuit of new solutions to complex problems, and the stimulation of treating patients with challenging problems are rewards for each day. I suspect that most of us who have a passion for this challenge could not imagine spending our time in any other career pursuit either inside or outside of medicine. If you are committed to the emotional, intellectual, and lifestyle concepts of an academic surgical career, running a division of cardiothoracic surgery may allow you to fulfill personal aspirations and make a meaningful difference.
The following insights into the process of becoming a division chief are personal and not meant to be a blueprint. There are numerous ways to reach goals. Every candidate brings a unique background and set of life or professional experiences to the chief position. Such diversity in backgrounds is essential to maintaining vibrancy and excitement. Each position also has a unique set of problems and as many unique solutions. When the match is right, both institution and individual benefit.
Academia is always in a state of flux. What seems like a solid foundation or set of rules for engagement in one era can rather rapidly change. Understanding the academic environment both locally and nationally is essential because priorities can differ substantially in two different regions, such as California and New England. Some resources necessary to achieve a level of success may be constant across all departments of surgery, all academic medical centers, or all schools of medicine. Divisional autonomy, clinical demands on faculty, title, administrative support, the likelihood of finding academic collaborators are examples of constant issues. On the other hand, some resources needed for success can be unique to a particular region or institution. Examples of unique local issues include inherited faculty, the rules of tenure, the quality of the current residency, the need to deal with an ongoing residency review committee probation, the penetration of regional managed care, patient case mix, and fiscal remuneration profile. Both constant and unique factors must be weighed in the decision to consider a particular chief position.
When you pursue a position of leadership within an academic medical center, you have to deal with at least four major concerns during the interview and after you arrive at your new institution. How are you going to make a contribution in the three major areas of academic responsibility—(1) clinical care, (2) research, and (3) education? At the same time, how are you going to develop the time, background, or experience in (4) administration to run an important, revenue-dependent division such as cardiothoracic surgery? There are few "triple or quadruple threats" out there with expertise in all four areas of responsibility. Each of these areas individually could consume one person's entire career in this marketplace. On the other hand, as a division chief, you must have a strategic plan and an operational system that can work within the new environment to bring some degree of identity to each of these areas. To do so, you have to be able to objectively assess the strengths, weaknesses, opportunities, and threats related to each of these issues. Tables I through III list some of the generic issues that must be understood as foundation concepts in each of these important areas of responsibility.
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Clinical environment
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To establish leadership within an academic medical center, a surgeon must first establish his or her quality as a surgeon. In bygone eras you might be an effective academic leader without a credible reputation as a surgeon, but such credentials are less likely to be successful in the current competitive clinical marketplace (Table I
). The US surgical specialty health care system has championed a decentralized approach to patient care. In addition, local hospitals are looking for ways to fill inpatient beds, and interventional cardiology programs want in-house surgical backup for their elective interventional procedures. We have trained excellent surgeons and sent them into the community. Such community medical centers then demand not only secondary surgical services but also tertiary and in some cases even quaternary services. Such local expansion of complex surgical services usually comes at the expense of the original academic medical center. Training programs become surrounded by excellent surgeons (often trained locally) capable of providing most of the routine and many of the more unusual surgical services, and they do this without carrying the burden of education or research. Because of changing certificate of need processes to enhance competition, the effect of managed care, decreased remuneration, and a cost shifting, vertically integrated academic health care delivery system, the clinical future of the academic medical center may be threatened unless the local environment is carefully assessed.
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Educational environment
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Teaching cardiothoracic surgery in the year 2000 is not getting easier (Table II). Most of our training programs last 2 years, and most of our residents going into practice perform both general thoracic and adult cardiac surgical procedures. Often the first year of cardiothoracic training is dominated by attempts to prepare and pass the American Board of Surgery qualifying and certifying examinations. The volume of bread-andbutter index operations for a training program may be decreasing. The case mix often reveals an increasing complexity of disorders among patients denied care in the community. In addition, new technology has introduced substantial challenges due to the marketplace demands of off-pump revascularization and minimally invasive incisions.
The knowledge base continues to increase. Surgeons in training need clinical experience in the nonsurgical components of cardiothoracic education—cardiothoracic anesthesia, cardiac catheterization, echocardiography, pulmonary medicine, and oncology. The opportunities to introduce new techniques and tools in surgical education are expanding with the introduction of concepts such as surgical simulation, robotics, and internet-based learning. Developing methods to determine competency over many years of practice as technology and surgical techniques change remains a formidable challenge and opportunity.
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Research environment
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The era of surgical descriptive physiology is rapidly disappearing. Although more research dollars are available for translational research than ever before, multidisciplinary research must be described, mechanistic biology must be emphasized, and a successful record in publication must be demonstrated to obtain funding at the national level (Table III). In many ways, funding is more accessible for those who understand funding principles, who have done preliminary foundation research, and who can write a comprehensible grant proposal. The surgical competition is not as vigorous as it was in earlier eras. The trick, of course, is finding a supportive environment, developing appropriate, respectful multidisciplinary interactions with basic scientists, asking the right questions, and making research a priority in an environment where clinical activity can always be viewed as a logical and appropriate excuse. Other areas for clinical research are outcomes research and clinical trials, but once again, meaningful clinical research requires priority and resources.
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Administrative environment
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Most of us received little or no formal administrative training during our residencies or in our junior faculty roles. Running a division of cardiothoracic surgery requires us to play different administrative roles concomitantly, such as department or medical center administrator. Training is needed to understand the complex health care marketplace in periods of rapid evolution (managed care) and to understand the essential components of leadership. National courses are available, such as those offered by the Harvard School of Public Health, to help with the essentials of these issues. The local administrative resources within the institution are essential to both short- and long-term success as a division chief.
Strength of advocate mentors
Receiving an invitation to become a candidate for a division chief position is a critical first step. Do not underestimate the importance of your advocate mentor. This usually is the person who trained you or is your most recent boss if you are a junior faculty member. Being recommended by a national figure with a proven track record of attracting and promoting surgical leadership is a bonus. Examples are the large numbers of division and department leaders in cardiothoracic surgery who worked at Johns Hopkins University in the 1960s and 1970s and the surgical leaders from the University of California, San Francisco, in the 1980s and 1990s. Pedigrees have made a difference in the past and likely will in the future. It is not impossible to become a division chief without a strong national mentor, but it most likely will require a longer apprenticeship and an extremely strong clinical, academic, or educational record. It also may necessitate considering a regional program rather than a national position.
Strategies to overcome stereotyping and role modeling
It cannot be denied that institutional stereotyping and individual role modeling occur. Most of these tendencies are subtle; others are obvious. Some institutions tend to consider only their graduates as potential division chiefs. They may interview an outside candidate but their record may reveal they chose only "their own." Interviewing for such a position may be good for experience, but you have to be careful to have realistic expectations concerning landing such a job. Some institutions may have less obvious historical tendencies toward hiring women or minorities into leadership positions. In the current marketplace, developing proactive strategies to deal with such tendencies can be beneficial and extraordinarily rewarding. What may be perceived as an institutional weakness might actually be a unique opportunity. The academic world is changing, albeit slowly.
Practice makes perfect
My mentor, Paul Ebert, MD, advised me to always interview for a position once, but to never go back a second time unless I was truly interested. That is good advice even if you know it is highly unlikely you or your family would be interested in moving to the other side of the country or to a particular institution. The process of evaluating an opportunity, developing a strategic vision, interviewing, and negotiating the proper resources is not a set of skills we are usually taught in residency or as junior faculty members. These skills are acquired with practice. Every time you go through the process you learn something, not only about the institution you are considering but also about yourself as a potential division chief. What are your administrative, clinical, educational, and academic skills and strengths? What resources do you need to complement your strengths or correct your weaknesses? How do you identify real or possible problems within an institution? Who are the key players you met during the interview process? What values or requirements are absolute or relative for you to seriously consider the position? Is this a move forward, or is it a lateral move? Your assessment, interviewing, and negotiating skills usually improve with each interview.
Do your homework
If you are interested in a position, you must do your homework. You must be prepared. First, you must have an open mind because much of what you hear may represent only one viewpoint, may be incomplete information, or may be prejudiced for one reason or another. It is important to obtain a number of views—within and outside the institution, locally and nationally, from present and former participants, and from advocates and critics of the institution or the division you are considering. All institutions have ghosts or detractors with a grudge. Sorting through what is real and what is not sometimes can be difficult. If the data or criticisms seem impossible to believe or interpret, that assessment is probably worth realizing because the problem may be greater than you can solve alone. You need to believe and trust someone, but where there is chaos there is usually opportunity. It is best that the person you trust most is your boss.
Interview skills
First impressions are lasting. There is both an art and a science to interviewing well. The concepts of personal grooming and body language seem simple but can ultimately hold more weight than you would imagine. Understanding the difference between quiet confidence and brashness is important. Recognizing the importance of listening well is essential. Sincerity, honesty, intensity, focus, and interest must be obvious. Being able to hold a social conversation about something other than medicine with your potential boss's spouse may be the key to successful recruitment.
Assessment skills
You have a small window during the interview to obtain a large amount of critical information followed by a short time to make an insightful assessment. Every job has a history, a present circumstance, and a potential future opportunity. Understanding the history can be helpful to understand both the obvious and hidden agendas, the strengths and liabilities of inherited personnel, and the foundations of academic, educational, or clinical strength on which to build. The current marketplace is under such flux, however, that looking at the future potential can be more meaningful if the institution has the resources and commitment to make meaningful change. It often is difficult to differentiate real commitment to change and "lip service" regarding change. This is where experience in assessment serves you well. During the assessment period, it is important to determine the major need of the recruiting institution and how that matches your strengths.
Some positions emphasize a desire to develop academics or clinical practice. Matching your strengths to the needs of the recruiting institution allows you to achieve early success. Another critical assessment is the opportunity to build your own team. If the inherited faculty is relatively young and possibly resentful of your arrival, and there is no opportunity to recruit strategic clinical or research partners, the opportunity may be suspect. Another critical assessment is collaborative resources, whether they be clinical (cardiology, cardiovascular anesthesia) or research (vascular biology, physiology). No one person can make a program successful regardless of the strategic vision. Another critical assessment is the critical relationship between you and your new boss, whether that is the dean or a department chair. All academic institutions have rigid hierarchies of responsibility.
Finally, what is your general sense of the new environment? Is it similar to your training or first faculty position? Are the people with whom you will spend much of your time the type of people you respect and enjoy? Table IV is a standardized checklist of resources to evaluate during the assessment phase.
Negotiating skills
The recruitment phase provides your best chance for negotiating resources. Once recruitment for your position is completed, another critical institutional recruitment will be necessary, and resources will be directed elsewhere. That means you must have not only a list of short-term needs but also a long-term vision that includes the resources needed to realize that vision. Because there are all sorts of "courses" in the business community for honing negotiating skills, there must be a science as well as an art to the process. You must be honest and realistic, respectful yet not bashful. The strategic vision and operational system you propose must be articulated so that the situation is an obvious win-win for both the institution and your professional and personal needs. It is best to keep personal needs off the table until the needs of the program have been defined. One of the most sensitive areas is determining which guarantees to get in writing. A lot of this has to do with trust and the other person's record for delivering on promises. Written promises give you a sense of security, which may or may not be real over time as institutional priorities change. Beware of the negotiator who starts by stating, "It is in my best interest for you to be successful. Trust me."
Understand personal strengths
The era of the individual "triple or quadruple threat" academic faculty member is waning as clinical, educational, academic, and administrative demands become more strenuous. Most academic medical centers or university programs, however, desire productivity in each of these areas. You have to mesh with the needs of your new environment. You must be provided an opportunity to build on your strengths, to assure the environment will tolerate your weaknesses or provide you with a support structure or educational environment to turn the weaknesses into strengths. Sometimes the opportunity for strategic recruitment is essential to form a cohesive and strong team. Honesty is essential. Do not promise what you cannot deliver.
Strategic vision
It is important to respect the past, understand the present, and define the future. During the final stages of recruitment, those hiring you want to be able to clearly understand your assessment of the environment—its strengths and weakness, threats, and opportunities. What then is a reasonable and achievable vision for both the short-term and the long-term? You must be able to articulate that strategic vision well and realistically.
Operational systems
How do you realize you're the vision with resources provided? There must be some freedom to design an operational system with which you are comfortable, that your faculty and administrative staff understand, and that is consistent with the restraints imposed by either the hospital or department. Timing of implementation is an issue because meaningful change often takes time, preparation, communication, and role modeling. A few of the issues related to operational systems are listed in Table V.
Respect your family's needs
You cannot move your family across the country without respecting their needs. It is almost impossible to be successful in these periods of transition without some degree of harmony at home. Moving to a new position as a division chief is a stress not only for you but also for those around you. The process of adapting to loss is prominent with such a move. Not only you but also your loved ones will feel anxiety, anger, and sadness. Job opportunities for your spouse, educational opportunities for your children, recreational activities available, or even weather can be formidable obstacles that must be overcome.
Random thoughts
Table VI shows some random thoughts that may be helpful as you ponder a particular division chief job offer. The thoughts are personal and are not inclusive. It is important to not underestimate the following concepts: (1) the need for a clinical profile (you will find few strong division chiefs who cannot operate), (2) the magnitude of the responsibility for education, (3) the difficulty in establishing an academic niche in the current marketplace, (4) the importance of developing administrative skills, and (5) leadership. Your success will be measured by the accomplishments of your team, not your personal accomplishments. You must take care of the people who rank below you in the institutional hierarchy and not to worry a great deal about those who rank higher. If you do your job, your boss will know. You have to assume the people who work for you are capable and competent, and you have to delegate responsibility early and often. Most times your team members will respond if they believe in the vision and respect your operational system. Keys to success include being fair, consistent, and honest. When you accept the position, you become responsible for a new extended family. Be careful what you wish for.
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Footnotes
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Read on April 29, 2000, at the Eightieth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada. 
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Abstract
Introduction
