The Care and Feeding of Chairs of Departments of Psychiatry

Two decades ago, John Romano wrote about the stresses of being a chair of an academic department of psychiatry, which he termed "the battered chairman syndrome" (1). There is no reason to believe that this role is any less challenging now. Academic medicine is under threat, with the disproportionate increase in uninsured care amid tight financial margins, flattening of National Institutes of Health support for research, rising debt among medical students, and a growing shortfall in support for resident education. These challenges require a broad skill set and tenacity (2). Additional challenges for psychiatry in particular include an 8% decline in medical students entering our profession over the past 5 years, anomalous and less favorable insurance practices for mental health care, and concerns about our capacity to train the next generation of psychiatric researchers. Difficulties in recruiting into chair positions and in retaining leaders in their roles are not unique to psychiatry (3). The 5-year retention rate among first-time chairs of psychiatry is 68%. There is a decline in the retention of chairs over time to a rate of 39% by 10 years. Despite what seem to be new and more formidable challenges, the rates of retention are remarkably similar to what they were when Romano wrote his article.

Similar problems and rates of retention of chairs in other specialties have also been described (3). While many chairs move on for enhanced opportunities, other reasons cited for short-term tenure include disagreements with the dean, institutional barriers, and lack of resources (4). There is also, especially for more research intensive departments, the chair's expenditure of his or her recruitment package earlier during the appointment, with the potential for deficits to accrue later on during tenure, a cycle that inherently promotes shorter tenures. On the other hand, it is well acknowledged that most academic leaders are most effective in the early and mid-phases of their position, with diminishing returns over time (5). Accordingly, a decline in the tenure of chairs after 10 years is not necessarily detrimental, especially when departmental problems repeat to rechallenge the chair. Indeed, it is intuitive that for both the department and chair, there comes a point of equipoise, where the chair is able to "move on" with enthusiasm to a new position and this is in everybody's best interests.

Given that this position is a time-limited but critical one for the advancement of our field and, in particular, for training the next generation of psychiatrists, perhaps more attention needs to be paid to the development of chairs. Most people do not aspire to become a chair, and they come to the position from varied backgrounds and expertise. Encouraging and cultivating this potential among faculty members should fall within the commitment of current chairs to the future of their departments and our profession (6, 7). Career development for future chairs should begin at a mid-career level so that potentially interested colleagues can receive the encouragement, exposure, and necessary experience. The American Association of Chairs of Departments of Psychiatry has a new program that involves mentorship and on-site visits with an established chair in psychiatry. Leadership development programs like the Harvard School of Public Health program, the Executive Leadership in Academic Medicine program, and the Association of American Medical Colleges Leadership Development program provide education in leadership skills and perspective as well as connections to a new peer group. Outcomes of mid-career leadership programs point to greater faculty satisfaction and overall professional competence (8).

The competencies needed by modern-day chairs have expanded from the tradition of academic excellence to encompass more complex managerial and leadership requirements. If particular leadership qualities are necessary to fulfill the more complex administrative roles of a modern-day chair (9), then this requirement has implications for recruitment into chair positions. Attributes such as emotional intelligence, visionary thinking, and motivational style are much harder to assess in prospective chair candidates than other still very important characteristics such as academic rank, research productivity, and educational acumen. Moreover, this search effort is further complicated now by the disproportionate financing of medical schools through their clinical operations, such that managerial and financial attributes of leadership often now rise to the top of the most desirable characteristics of prospective candidates.

Mentorship and supervision, so important in most aspects of psychiatric training, may not be as readily available for leaders as it is for other members of their department. Support and training of new chairs by more established chairs, both those in other disciplines in the same school and those who are psychiatry chairs in other schools, may be helpful for ensuring the initial tenure of new chairs. Fellow chairs may be the best equipped to appreciate the rewards and disappointments as well as to offer strategies to deal with opportunity and crisis (6, 7, 9). On the other hand, a recent study by Gabbe and colleagues (10) suggested that this mentoring is best accomplished by pairing up new chairs with senior chairs within their own institution, since distant mentoring (even though it involves chairs within the same specialty) does not appear to confer any advantage. Ex-chairs within the department are another potential source of support, although this approach also creates the potential to undermine the new chair's role. Former chairs do, however, have a unique perspective, and when this tension can be managed, they can be particularly helpful in grooming and providing direction to aspiring chairs.

Whichever avenues senior faculty chooses to advance toward an aspiring chair, it is important that our colleagues receive our support early on and that they be directed toward appropriate mentors and leadership training resources. In this regard, recruitment, retention, and professional development of senior faculty who may aspire to become a departmental chair are important workforce considerations for our profession.