The search for leaders is an important challenge facing our academic medical institutions. When the recruitment of a dean, department chair, or section leader is successful and the right person is matched to the opportunity, our institutions may reap benefits for years or even decades to come. However, not all searches end successfully, and in some cases the consequences of failure have proven to be dire. Because a truly outstanding leader affords a department so many benefits, and because a poor one can harm a program in so many different ways, it is vital that we devote serious time and attention to how our organizations recruit and retain good leaders.
Two of the greatest dangers in securing a good leader are ignorance and apathy. Departments and medical schools that are preoccupied by other demands may neglect the process, not investing the time and energy it deserves. They may falsely presume that their momentum is so strong that they will continue inexorably forward along their current trajectory, no matter who is at the helm. Given sufficient time, however, even the greatest organization can be undone by poor leadership. With so much at stake, it is remarkable how little time and attention many organizations devote to the development, recruitment, selection, and retention of leaders.
Many academic physicians have received little or no formal leadership training. The structure of medical school and residency tends to focus our attention on individual initiative and achievement, not on the collaborative approaches on which effective leadership depends. When it comes to finding a chair, some departments have little experience and simply rely on administrators to carry out the search and screen process. Such an approach may work if administration thoroughly understands the particular medical specialty involved, but this is not always the case. Given that the members of the particular department will work most closely with the new leader for years to come, it is logical that they should play an important role in helping to select their future leader.
We must guard against the tendency to stop investing in leadership the moment we secure a new leader. Many leaders receive little regular feedback on their performance except complaints. Words of encouragement and praise are infrequent, and everyone tends to assume that because leaders occupy the most prestigious and best-compensated positions in the organization, they must be thriving in their jobs. We forget what a lonely post leadership can be.
When leadership posts become vacant, it is vital that we conduct serious national searches. If department chairs are quickly replaced by individuals focused solely on the clinical mission, then academic missions such as education and research may suffer. The future of every field in medicine depends in large part on how effectively we educate the next generation of physicians and how well we push the envelope of medical research. If people with deep commitments to the academic missions do not lead the academic departments, all of medicine will eventually suffer. It lies in the best interests not only of medical schools but departments and sections themselves to recruit leaders with strong academic commitments.
What harm can a poor leader do? An ineffective leader can misrepresent the program poorly within the health center and medical school, squandering important opportunities for collaboration and growth. An insensitive or arrogant leader may offend people both inside and outside the program, damaging morale internally and creating enemies externally. An insecure leader may perform poorly at delegating responsibility, thereby stunting the leadership development of other capable people. An unenlightened leader may unwittingly undermine the cohesion in a department by adopting budgets and incentive systems that pit parts of the organization against one another. A socially inept leader may compromise recruiting and retention. In the worst-case scenario, a leader's duplicity may sow the seeds of distrust throughout an organization.
Transitions in leadership represent vital stages in the life of an academic medical organization. When a successor can be appointed far enough in advance, it is possible to avoid long vacancies and promote smooth transitions. On the other hand, numerous problems may befall a program that encounters a long leadership vacancy. The lack of a leader can delay important organizational choices, foment a general atmosphere of indecision, inhibit recruiting, and leave the department vulnerable to others who may not have the best interests of the organization at heart. People may begin looking elsewhere for greener pastures, exacerbating staff shortages. As some leave, those who stay behind may become increasingly overworked and discouraged. This can initiate a vicious spiral of departures and discontent.
Because those who remain in place find it more and more difficult to get the clinical work done, other missions such as education and research may begin to suffer. Sheer uncertainty may compromise recruitment of faculty, fellows, and residents, only exacerbating personnel shortages. As a result of these and other consequences of a leadership vacancy, programs may appear less and less attractive to prospective leaders, particularly candidates with strong academic aspirations.
Promptly naming an interim leader often proves less effective than hoped. People both inside and outside the program tend to take such a leader less seriously, because of the impermanence implied by the interim title. Evidently, the organization is not strongly committed to such a leader, and the decisions that person makes may soon be reversed once a permanent leader is named. If people recognize that the interim leader is a "toothless tiger," the sense of cohesion and discipline may deteriorate.
Why have so many leadership vacancies opened up in our academic medical organizations? One difficulty is the competition between different departments, which can force leaders into decisions that alienate large groups of constituents. Another is the failure of some programs to develop lieutenants with whom leaders can share some of their responsibility, such as associate deans and associate department chairs. Particularly in larger organizations, such administrative structures can be crucial to a leader's effectiveness and longevity.
A third difficulty is the often-stunted intellectual life of leaders. If academic medical centers are doing our jobs properly, we will appoint to leadership positions people with strong academic credentials who have devoted good portions of their lives to education, research, and other academic pursuits. Although often superb clinicians, they care about more than the clinical mission. Yet if clinical operations, fund-raising, or adjudicating disputes occupy all of their time, they may lose enthusiasm for the job when they sense that their intellectual interests and abilities are atrophying.
A search for a new leader should prompt serious examination of the organization itself, not just the candidates who are going to lead it. Important questions need to be asked, both by the program itself and the candidates who interview for the position. Does the organization have in mind a clear picture of its own mission? How effectively has it been able to achieve it? What resources are available to pursue its goals? What additional resources are needed, and is the institution prepared to pursue and provide them? What are the most important weaknesses of the organization? Will the new leader have the authority and tools necessary to redress them? What external challenges face the organization, and what plans are in place to meet them? Are there any skeletons in the closet that a prospective leader would want to know?
What is the culture of the program, in terms of its commitment to excellence, its approaches to communication and problem solving, and past leadership styles? How great a challenge would it be to lead this particular organization? Is the organization prepared to invest in the leader's development as a manager and a leader, and what opportunities could it make available? What is the level of commitment of the larger organization to the program seeking a leader, such as the university to the medical school, or the medical school to the department? What role would the program be expected to play in the larger organization's strategic plans?
When candidates interview for a leadership position, it is important to adopt the perspective of the long-term interests of the organization. The search and screen process should quickly weed out candidates whose primary interest focuses on their own personal success. Such candidates may be merely using the organization as a springboard to their own advancement. The program should also attend to the opportunity represented by a leadership transition to secure greater support from the health center and medical school. Rather than being flattered at being considered for a leadership position, serious candidates should function as the department's advocate, basing their negotiations on the needs and opportunities of the program.
Major bargaining points might include new equipment, more space, new or renovated facilities, new faculty, administrative, or training positions, enhanced compensation for colleagues, a greater voice for the program in key decision-making forums, a larger discretionary fund for the new leader, resources for the continuing education of faculty and leadership, and a role for the program in fundraising initiatives.
No academic physician should seriously consider a leadership position unless we are prepared to make an earnest commitment to the flourishing of the program. Ironically, the recruitment itself represents one of the best opportunities a prospective leader will ever enjoy to promote that success. When a candidate leaps immediately at the chance to assume leadership, the program loses an important bargaining opportunity, and a good leader will recognize such conduct as a sign of weakness that may ultimately work to the detriment of both the program and the institution.
What are the attributes of an excellent leader? Key questions need to be addressed. Is the candidate a person of integrity? Is the candidate an autocrat or a team builder? Is the candidate aloof, someone who acts independently and shoots from the hip, or someone who consults with others before making important decisions? Is the candidate good with people, and someone others look up to and with whom they feel comfortable? Will the candidate promote two-way communication throughout the organization, thereby enabling everyone to make better informed choices?
Is the candidate patient, someone who can resist the tyranny of the quarterly report and do what the longer-term interests of the organization dictate? Is the candidate gifted with common sense, the ability to see through clouds that obscure the foresight and judgment of others? Is the candidate capable of making tough decisions and delivering bad news? Will the candidate be able to cope with adversity and maintain a clear sense of purpose amidst an atmosphere of crisis? Can the candidate remain committed and energetic in pursuit of the organization's mission in circumstances where others might throw in the towel?
What mistakes has the candidate made in the past, how did he or she respond to them, and what lessons did he or she learn? How much insight does the candidate exhibit into his or her strengths and weaknesses as a leader? Is the candidate a respected academic physician? Does he or she bring a proven track record as an educator, researcher, or administrator? Is the candidate able to articulate a clear mission for the department and the role he or she would play in achieving it? How well does the candidate understand the department and the larger institution and healthcare environment in which it is situated?
A good leader must be prepared to deal with personnel issues that might seem trivial to an outside observer but are crucial to the people involved. Many of these issues, and perhaps 90% of what many leaders do, generates as much frustration as fulfillment. Yet the leader must be able to see past those responsibilities that are not intrinsically fulfilling and derive satisfaction from the 10% of activities that are truly challenging and enjoyable. Confronting complex issues and problems is part of the leader's mission, and he or she must earnestly engage such challenges, despite the fact that many are neither genuinely interesting nor rewarding: In this respect, good leaders must be not only unselfish but also optimistic, and capable of fostering optimism in others.
The measure of excellent leaders is not how famous they have become, but how well their programs have fared under their leadership. Great chairpersons focus less on their own achievement than on that of the organizations they lead. They are able to subordinate their own ambitions to the needs of the program, the institution, and the community. Their chief responsibility is not to propel themselves to national or international prominence, but to find satisfaction in the success of their colleagues. What the leader does is less important than what the leader enables others to do, and many talented people have failed precisely because they could not make the transition from working for themselves to working for others.
The leader's mission is to recruit and retain good people, to nurture the abilities of others, and to recognize and reward excellence. High achievers may not make the best leaders. The need of such people for personal achievement may override their commitment to the best interests of the organization. In most cases, a good leader more closely resembles the coach of a successful sports team than its most outstanding individual performer. To determine whether a candidate genuinely seeks to serve, a selection committee should carefully seek out evidence of service, past coaching and mentoring, and in general, a commitment to meeting the needs and promoting the flourishing of others.
Those selecting leaders need to assure themselves that candidates understand the organization's mission. How much time does the candidate believe would be necessary to excel on behalf of the program? On what other professional pursuits, such as education, research, and clinical work, would the candidate propose to focus? What are the candidate's personal commitments, and how would he or she balance professional demands with those of family and community? For the right person, formal leadership opens up new possibilities for professional fulfillment. For the wrong person, however, serving as a leader can be a painful experience, at best merely interrupting an otherwise successful career.
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