So, You Want to Be a Chair?

The following represents the major themes of one of the honored guest presentations at the 2024 Congress of Neurological Surgeons meeting in Houston, Texas. I want to thank Alex Khalessi and the Executive Committee for the designation and the honor bestowed on me. I also want to congratulate Alex for his leadership role in the Congress this year and many future leadership roles that he will assume. In anticipation of next year, I want to congratulate the president-elect of the Congress of Neurological Surgeons Dr Dan Hoh, who also trained at USC. Once designated as an Honored Guest, one of the harder tasks was to select a topic. Any contributions I may have made to our specialty would have come under the topics of cerebrovascular disorders, cranial base surgery, and participation in our national educational and regulatory organizations, but having recently stepped down as the chairperson of the Keck/USC department of neurosurgery, I have been forced to reflect on all the advising of faculty, staff, residents, and fellows a chair is called on to do related to personal, clinical, research, and career matters. As our faculty mature and become successful in their clinical and scientific endeavors, inevitably their thoughts will turn toward musings related to leadership scenarios. Given the accomplishments and successes of our USC faculty, “So, you want to be the chair, huh?” is a phrase I found myself using with some frequency. I thought I would try to organize my thoughts on lessons I have learned (many the hard way) on department leadership. Some of the following is personal anecdote with supplementation from tenets gleaned from business and military leadership principles. WHY POSE THE QUESTION? My goals are to give a pep talk, but it is also a cautionary tale. There is a price to be paid in taking the helm of a moderate-sized department, and I will try to illustrate some of the challenges. My experience is only in the academic sphere, so it is my hope that what I have to say about leadership works for both of our academic and practice/employed disciplines. Why post the question in the first place? We just had a major change in the leadership of our department at USC; Bill Mack is now the chair, succeeding me. When that happens, there are ripple effects. Many start thinking about their own potential for leadership roles and ask themselves if they can make a difference in their own careers and in the careers of their colleagues as the chair. Do they have leadership capabilities that are perhaps untapped? That generates opportunities and obligations for the existing chair and senior faculty to advise our younger colleagues on the advantages or disadvantages of those kinds of leadership roles, and frankly, in neurosurgery, we have a lot of talent. We have a huge talent pool for leadership. If you think about the metrics that we use to select residents, one of them is their experience with leadership, and so, in effect, most of the people in this room have expressed leadership capabilities, starting probably from college, if not even high school. However, when considering a chair job in a neurosurgery department, the numbers do not add up. If you think about the academic side, there are only 118 neurosurgical training programs, and there is a relatively low turnover rate, so these jobs do not come up very often. I was talking to Henry Brem during the summer. He said he is been the chair for 25 years. I have been the chair for 20 years. Furthermore, to the extent that people consider being a chair an honorific, all that does is make the quest even more competitive, but again, it comes with a price and there are positives and negatives to that career choice. If you think about it, a chair position is not necessarily mandatory for success or even recognition. I will give you some examples in my sphere. When I was at UCLA, most of the people that I came in contact with thought Bob Rand was the chair of neurosurgery, when in actuality was Gene Stern. Similarly, I was a young vascular, or wannabe vascular neurosurgeon, and one of my heroes was Bob Ojemann at Massachusetts General. I just assumed Dr Ojemann was the chair when all along it was Nick Zervas. Then, at USC with Marty Weiss, we all know of the international fame of Dr Michael Apuzzo, who was in our department. Many of our international colleagues assumed that Dr Apuzzo was the chair of the department. Clearly, these individuals did not need any extra recognition as chair. Many of us are aware that some of our icons in neurosurgery were chairs at one point in time in their career and then gravitated toward some other area of expertise and are certainly still iconic in our minds. DEVELOPMENTAL STAGES TOWARD LEADERSHIP I have a muse for this. Ralph Dacey, as many of us know has served neurosurgery in almost every leadership level including as a department chair, and since Ralph cannot travel, I made a pilgrimage to Saint Louis, and I spent the weekend with Ralph and Corinne. We talked at length about our experiences with being chairs of departments, and we laughed a lot, frankly, which was one of the purposes of my visit, but one of the things I wanted to talk to Ralph about was an article he published in Neurosurgical Focus in 2018, entitled “The Developmental Stages in the Career of the Academic Neurosurgeon.”1 As only Ralph can do, he wrote this beautiful single authored treatise on a paradigm for the ascendancy to leadership, especially in the academic sphere. Categorizing and cataloging those objectives, milestones, and skills required to ascend toward excellence in the clinical, research, and leadership domains. As an example, excellence in the clinical domain is characterized as clinical legacy mode. This follows on the progression from adaptive enculturation of early residency, autonomous integration of senior residency, initial mastery at the assistant professor level, and consolidated competence as a senior surgeon in the teaching environment. The clinical legacy designation is reserved for those individuals whose practices have engendered national recognition. These surgeons spend much of their time advising and supporting their colleagues and formally or informally perform many of the leadership duties inherent in the department chair role. Those who combine their clinical successes with similar level research accomplishments will naturally be considered as prime candidates for departmental leadership (Figure 1).FIGURE 1.: Departmental leadership.WHAT MOTIVATES THE CHAIR CANDIDATE? I started to put together a list of my own creation comparing positive versus not so positive reasons to seek a chairmanship position. While I was doing that, I came across some American Association of Neurological Surgery sponsored interviews, posted on YouTube, of our icons and leaders in neurosurgery. Brad Elder, another alumnus of our USC neurosurgery training program, interviewed Nino Chiocca focusing on when he took over as chair of the Ohio State University program. Nino admitted: “I was plateauing. Wanted more for my personal development, more lab space, more lab funds, more of OR time. More, more, more. Wouldn't it be great to be a chair? That way I can have total control of what I want to do. I quickly learned upon arriving at Ohio State that it wasn't about me. It has to do with your team.” Nino's much more eloquent admission reminds me of my much less eloquent aphorism when asked about the benefits of being the ‘Boss’. To whit, “when you become a chair, it ain't all about you anymore. It's about everybody else.” ARE THERE WAYS TO PREPARE? There are literally 1000s of books on leadership. My personal library is heavily weighted toward military authors. Most others are lessons learned from business authors. What can they do? Well, my sense is mostly they can validate your instincts. They can answer the question: do I fit in this role? Most of the best sellers describe leadership styles, both positive and negative. “Good To Great” by Cooper is one of the best examples of that genre. Anecdotes and tactics of successful leadership are not only informative but frequently entertaining. Andrew Carnegie's “How to Win Friends….” published in the 1930s is still one of the best examples. Will such writings inspire somebody who does not have an inclination to be a leader to subsequently accept leadership roles or leadership training? I do not quite think so, but what they really do is they identify styles and qualities of excellent leaders. Can one find the playbook for Neurosurgical department success? Nope. Sorry, that is on you (Figure 2).FIGURE 2.: Levels of leadership.DEFINITION OF LEADERSHIP Another reason there is probably a lot of books on leadership is the lack of a universally accepted definition. I was watching an entertainment TV show, and they were interviewing Steven Spielberg. The interviewer asked “what's your definition of leadership?” Steven said, “my definition of leadership is everybody running around doing what I tell them,” and I thought, yeah, that works for me really well, but that was not the definition cited in Ralph Dacey's treatise. To his point, leadership is creating the conditions in a group, whereby the outcome of the team's activities is optimized. That word ‘teams’ emerges again, brought up by Nino Chiocca from his American Association of Neurological Surgery interview. Lack of definition notwithstanding, the characteristics of effective leadership have been promulgated by many authors. Jim Collins2 and his team, in Good To Great found these floundering companies that were resurrected under new leadership. They investigated the actions and the mannerisms of the CEO who was responsible for the turn around. They catalogued the steps in that ascendancy to high-level leadership and created the pyramid seen in Figure 2. Their conclusion after exploring a number of corporate turn arounds was that there is a leadership style that is most correlated with success for the team. That style was labelled the Level 5 executive. The Level 5 leader builds enduring greatness through a paradoxical blend of personal humility and professional will. Certainly paradoxical. What does my favorite general, Colin Powell, think about books on leadership? See his quote in Figure 3. I am not sure the general holds a lot of these books in very high esteem.FIGURE 3.: Colin Powell quote on leadership.DO I NEED AN MBA? After all, it is a business we are running, and a lot of my advisees have asked me that question. I started thinking about all the search committees that I have sat on at Keck. Frankly, less than one-third of the current chairs in our medical school have an MBA. Well, there may be great personal and professional reasons for getting an MBA, but, in most academic institutions, there will be a skilled financial leader (usually not a physician) assigned to each department. Furthermore, there are other options to gain leadership and financial skills without investing a couple of years in a purely academic environment. Many health systems and medical schools are generating their own leadership courses sculpted to the needs of medical executives. HOW DO I GET ONE OF THOSE JOBS? How do I get one of those jobs? Well, it depends on what system you are in. If you are in a private practice or an employed system, you may ascend to the job, in which case you are going to probably be answerable to (and will have to impress) several layers of medical and corporate leadership. But if you are seeking a position in the academic sphere in a medical school-based department, you are probably going to face a national search committee, and that committee is going to be associated with a headhunter firm. These firms are extremely subspecialized, and they actually get to know candidates almost on a personal basis. Their role is to not only assist the institution but also to assist you. If you are offered an interview, remember it is an audition. Do your homework. Make sure you know the needs of whatever department is your target and also understand who is going to make the ultimate decision and who your boss is going to be, whether it is a Dean or a CEO. Ralph Dacey emphasizes this point. Make sure that you know that you can get along with that person. When you are questioned, you will be asked to describe a dynamic, strategic vision for your new department. You will be questioned about a strategy that encourages growth. Of course, you will be asked to expand your scope of educational activities and how they will now include students, staff, faculty, and even the patients. Diversity, equity, inclusion (DEI) will be on the search committee's list of questions. This could be a tripwire. These committees do not want to hear platitudes about how you support the goals and objectives of diversity, equity, and inclusion. What they want to hear is your own track record and your results in furthering the goals of DEI in your current institution. In addition, be ready for that fiscal sustainability topic. Even without the MBA, be armed with a strategy you bring from your current department. The word alignment will come up a lot when interviewing for university/medical school–based department. They are talking not so much about aligning with neurology and orthopedics, etc. They are talking about alignment with other departments within the medical school and other schools within the university. How can you leverage the expertise of the biomedical engineering school, for instance, in furthering your new departments research goals of the care model? GET TO WORK All right, now that you have the job, set the vision you promised them. If you are ascending to the role in your current department, there may not be much change in culture that you need to affect, but now the scale and scope of your traditional academic surgical duties goes up. I asked Kathy, my secretary, when our faculty got up to 25 surgeons, “why is there over 100 people on the Christmas party list?” and that did not even include the plus ones. Now, all manner of people will be in your office getting coaching and advice from you. One of the most important roles of the chair of a department in an academic organization or even in a practice organization is advocating for your division or your department. ‘Fortress Neurosurgery’ was a term that John Jane taught Ralph Dacey, and it refers to a balance between advocating for your department versus advocating for the enterprise. When that balance shifts more toward your department, the term ‘Fortress Neurosurgery’ becomes a pejorative. KEY TO SUCCESS Assuming your new role includes oversight of a residency and/or of fellowships, your Coordinator and Program Directors are critical to departmental success. Choosing the coordinator position cannot be emphasized enough. Some erroneously assume that the job entails mostly paperwork and thus give it to the lowliest secretary in the department. The coordinator is your direct connection to the Graduate Medical Education Committee of your institution, the Residency Review Committee of the Accreditation Council For Graduate Medical Education, and the residents. The coordinator develops a special relationship to the trainees and also serves as an advocate for them to the faculty and the hospital. The Program Director is another extremely important role. That person must engender the respect of all the residents, but, equally as important, the program director has to have the respect of all the faculty. It is the program director who directs the faculty regarding the learning environment. To that end, the PD should be of substantial academic rank. Throughout the history of Keck/USC, every program director has been a full professor. Notwithstanding all the added chair duties, it is really important for the chair to maintain his or her surgical focus and expertise. It generates credibility, and it sustains trust, not only within the department but also the enterprise at large. General Powell discussed the importance of trust when he was asked by a White House intern what the key characteristics of effective leadership were that allow you to be an advocate for good. His response was “Trust. Good leaders are people who are trusted by followers.” THE PRICE All right, that is the pep talk. Now, the price. What keeps you up at night or a few nights? Figure 4 is a list of challenges recently experienced in our department. Is this an exhaustive list of the disagreeable events that have to be tackled at the chair level? The answer is absolutely no. In fact, this list is a paint up, clean up, and fix up list for me to make sure that department was in good shape when our new chair took over.FIGURE 4.: What keeps you up as a leader.In the interest of brevity, lets select one. At some point, we all have to face the issue of the failing resident. We know the stats.3 Up to 15% to 18% of residents at any given time might be in some trouble regarding deficiencies. We know the deficiencies. We know the interventions (Figure 5), but the outcomes are what is important. Happily, about half of the residents identified as deficient ultimately either graduate or stayed on track, clearly a positive outcome. A second group with a positive outcome, in my view, are those who ended up transitioning to another specialty, which probably better fit their skill set. The untoward outcome is represented by the group that went to another neurosurgery training program, probably setting that resident up for failure and not doing the next department any good either. If we fumble this delicate situation as program directors and department chairs, at the very least the Graduate Medical Education Dean will be all over us and at the very most the attorneys will be in our office.FIGURE 5.: Recognizing time for intervention.CHAIRPERSON AND BEYOND? Carrying out successfully the role of neurosurgery department chair leads to an inevitability. You perform well within your organization of chairs, and you are tapped for other roles within the school or possibly the university. By my count today, there are of medical schools who are Furthermore, there are people in this room who are of major health the opportunities for enterprise leadership especially when one the need for leadership of our national educational It is to of the toward enterprise leadership from the more traditional and control activities during I you with said, as the of a than