Interim Department Chairs in Academic Medicine

Academic health centers are experiencing more frequent turnover of department chairs. In departments of obstetrics and gynecology, doubling of annual turnover rates for chairs occurred between 1981 and 2005 (6.0% to 12.7%).1Rayburn W.F. Schrader R.M. Artal R. et al.Tenure of academic chairs in obstetrics and gynecology: a 25-year perspective.Obstet Gynecol. 2006; 108: 1217-1221Crossref PubMed Scopus (17) Google Scholar During the time period from 1993 to 2003, the median length of service of chairs in pediatric departments was 5 years with a mean annual turnover rate of 17%.2Stapleton F.B. Jones D. Fiser D.H. Leadership trends in academic pediatric departments.Pediatrics. 2005; 116: 342-344Crossref PubMed Scopus (30) Google Scholar Only 10% of individuals served as chair for the entire 11-year period of the study. The average tenure for chairs of departments of internal medicine at US medical schools declined from 5.2 years in the 1970s to 3.9 years in the 2000s.3Ringenbach J.L. Ibrahim T. Tenures for department chairs: how short is too short?.Am J Med. 2008; 121: 163-168Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Conversely, the average length of an interim chair's service in internal medicine departments increased from 1.3 to 2.3 years during the past 4 decades. In this same study, the authors reported a significant increase in the number of interim chairs who went on to become permanent chairs (4.5% in the 1970s to 26.25% in the last decade).3Ringenbach J.L. Ibrahim T. Tenures for department chairs: how short is too short?.Am J Med. 2008; 121: 163-168Abstract Full Text Full Text PDF PubMed Scopus (10) Google ScholarPerspectives Viewpoints•Interim chairs are being appointed more frequently, serving for longer periods of time, and increasingly assuming permanent chair positions.•The most important role as interim chair is to provide stability during a time of transition and establish transparency with open and frequent communication.•Interim chairs identified issues relating to people, communication, and finances as their most significant challenges. •Interim chairs are being appointed more frequently, serving for longer periods of time, and increasingly assuming permanent chair positions.•The most important role as interim chair is to provide stability during a time of transition and establish transparency with open and frequent communication.•Interim chairs identified issues relating to people, communication, and finances as their most significant challenges. The data suggest interim chairs are being appointed more frequently, serving for longer periods of time, and increasingly assuming permanent chair positions. Although the appointment of interim leadership is a common tool used by presidents and deans to fill gaps created by the departure of permanent leaders, the literature related to interim department chairs in academic medicine is limited. What are the key expectations for interim chairs? What are their most significant challenges? What advice should be given to a newly appointed interim chair? This article explores the interim chair role from the perspective of the interim chairs themselves. When referring to temporary leadership, many institutions use the terms interim and acting synonymously. In this article, we clearly differentiate between them. An interim chair serves as the leader while a search is conducted to find a new department chair expected to occupy that role indefinitely or for a specific term of service. In contrast, a person filling the leadership role while the permanent leader experiences a temporary absence, but who anticipates returning, is referred to as an acting chair. Temporary absences can be created when leaders opt for sabbaticals, periods of focused study, vacation, or sick leave, or leave under the terms of the Family and Medical Leave Act. No matter the purpose of the period of leave, there is a clear expectation that the leader will return to the position. Finally, we use the term permanent to refer to the full-time or sitting chair (recognizing that all chairs are ultimately “interim”). Penn State Hershey College of Medicine provides a unique opportunity to study the role of interim department chairs in academic medicine. After a failed merger with Geisinger Health System in 1999, Penn State Hershey College of Medicine experienced a profound transition of senior leadership.4Mallon W.T. The alchemists: a case of failed merger in academic medicine.Acad Med. 2003; 78: 1090-1104Crossref PubMed Scopus (18) Google Scholar From July 1, 1999, to June 30, 2007, 18 of 23 academic departments (78%) experienced interim leadership. To learn more about the experiences of interim department chairs, the authors invited individuals who served as interim chair to participate in a qualitative research project consisting of a web-based survey and a single focus group discussion. The participants were invited to complete an anonymous online survey regarding their role as interim chair. They were given 4 weeks to complete the survey. The survey consisted of a series of open-ended questions and explored a variety of issues, including prior leadership experiences; the development and impact of mentors; identification of the most significant challenges of the interim chair role; specific actions thought to be helpful/detrimental to success; and advice for newly appointed interim chairs. The authors analyzed the responses to each question and reached consensus on the main themes generated by the participants. A single focus group composed of persons who had completed the interim chair survey was convened in April 2008. The purpose of the focus group was to validate the themes generated through the analysis of the survey responses and to provide the participants the opportunity to discuss additional issues relevant to the interim chair role. One author (RKG) with experience in focus group facilitation served as convener and facilitator, and the other authors participated in the role of “participant observer” because both served in the role of interim chair before appointment as permanent chair after national searches. To guide the focus group discussions, a set of questions was adapted from earlier work by Betof and Harrison5Betof E.H. Harrison R.P. The newly appointed leader dilemma: a significant change in today's organizational culture.Manchester Review. 1996; (reprint 96001)Google Scholar citing several factors that “derail newly appointed managers/executives.” Written notes were taken during and immediately after the focus group discussion; the notes were then analyzed by the authors. The study was approved by the Penn State College of Medicine Institutional Review Board. Twenty-three individuals (20 male and 3 female) served as interim department chair from July 1, 1999, to June 30, 2007. All were appointed by a single dean. Sixty-five percent (n=15) of the interim chairs were from clinical departments, and the remaining 35% (n=8) served basic science departments. The duration of service ranged from 6 to 42 months with a median length of service of 13 months and a mean length of service of 19 months. Seventy percent (n=16) served for 20 months or less; 30% (n=7) served for more than 20 months. Two of the chairs were vacated because of unanticipated sudden death of the persons serving as chair. One chair was vacated because an individual retired. Twenty chairs were vacated when individuals left the organization to accept jobs in other organizations. By the conclusion of our study, 7 individuals who served as interim chair were appointed permanent chair after a national search. Three individuals remained in the interim department chair role. Five individuals served in alternative leadership positions within the organization (including Vice Dean for Research and Graduate Studies; Chief Quality and Safety Officer; Vice Chair for Research in another department; Associate Dean for Administration; and interim chair in a second department). Six individuals returned to their respective departments as professors. Two individuals left the organization (one to lead a clinical practice at a local hospital and the second to assume a senior leadership position at a major academic health center). During the study period, the mean number of vacant chairs was 5, with at least 1 chair position under interim leadership at all times. Eighteen of 23 interim chairs completed the online survey, yielding a 78% response rate. Sixty-one percent (n=11) of the respondents served clinical departments, and 39% (n=7) served basic science departments. Nearly all of the survey respondents (89%) held leadership positions before their appointment as interim chair. Leadership roles included: vice dean, associate dean, vice chair, division chief, residency program/fellowship director, and committee chair. None of the survey respondents were actively seeking chair positions at the time of their appointment; however, 39% of interim chairs had applied or interviewed for chair positions in the past. Serving as interim chair was influential in the decision to pursue the full-time position for the majority of respondents because it provided “real-life opportunities” to “test drive” the chair position. One interim chair commented: “Serving as interim chair strengthened and solidified my leadership potential.” Others noted that serving as interim chair did not influence their decision because they had no interest in the full-time position from the outset. Eighty-three percent of respondents had formal training in administration or leadership before or during their interim chair period. Approximately one half (47%) of the respondents believed this training was helpful. Training experiences in leadership and administration included a variety of internal and external programs, such as the Penn State Hershey Center for Leadership Development, Harvard School of Public Health Program for Chiefs of Clinical Services, and Executive Leadership in Academic Medicine Program for Women. When asked about their most important role as interim chair, the need to provide stability during a time of transition was a common theme. Comments included the following: “keep the ship from sinking until a captain is hired” and “provide an environment of stability in the face of a storm.” The interim chairs believed it was important to promote core values such as trust, fairness/equity, and accountability. Establishing transparency with open and frequent communication was another theme. One chair noted that it was important to “develop open lines of communication in order to limit rumors and negative thoughts from taking over the department.” The interim chairs surveyed identified issues relating to people, communication, and finances as their most significant challenges. In terms of people and communication, they commented on the importance of improving poor morale among the faculty and staff; communicating the department's mission and values within and outside the department; dealing with difficult faculty; and delivering difficult information. Typical financial challenges included department budgeting and faculty compensation. Individuals were asked if there were any specific actions taken at the onset of their interim chair period they thought were helpful to their success. Three themes emerged: communication, strategic planning, and personal growth and development. Many respondents stressed the need for open communication and dialogue through individual faculty and departmental meetings. In terms of personal growth and development, cultivating mentors was viewed as very important—particularly for more junior, less-experienced interim chairs. The majority of survey respondents (61%) established relationships with mentors during their interim chair period, and 82% of these individuals described their mentoring relationships as “very important” or “essential” to their development. Sited mentors included department chairs and members of the senior leadership team. Mentors were used for modeling/role identification, support, and advice. One interim chair commented: “Without the confidential support from 1 or 2 key experienced administrators, this role would have been much more difficult.” Reflecting on the importance of developing mentor relationships, another respondent noted: “learning that almost everyone shared some of the same problems, that there were people willing to share ideas with me, and that the successful chairs were no more Superman than me.” When asked what specific actions taken may have been detrimental to their overall success, a variety of comments were made but no general themes emerged. These included failure to delegate responsibility; failure to seize strategic opportunities; infrequent communication with faculty; and failure to adjust personal workload activities. Although the majority of respondents did reduce their patient care, education, or research activities to accommodate their increased administrative responsibilities, failure to do so was detrimental for at least 1 interim chair: “I tried to do it all with bad outcomes to all concerned, including my family.” Survey respondents were asked what advice they would give to newly appointed interim chairs. Establishing clear expectations from the dean for the interim chair period was considered an important first step. The most frequent recommendation was to cultivate mentors among fellow chairs and senior administrators. Several respondents encouraged new interim chairs to lead actively rather than assume a placeholder role. Interim chairs were encouraged to communicate openly and often. The concept of “limit and balance” emerged; interim chairs were encouraged to adjust their work responsibilities as a result of their increased administrative role. Finally, interim chairs were encouraged to identify critical, time-sensitive needs and seek “quick win” opportunities to demonstrate leadership effectiveness. Twelve of the 18 interim chairs who completed the online survey participated in the 2-hour focus group discussion (yielding a 66% focus group participation rate). Sixty-six percent (n=8) of the focus group participants were from clinical departments, and 33% (n=4) were from basic science departments. Very early in the conversation, common elements for the interim chair role became clear despite the diversity of individuals and transitioning departments. Key concepts expressed were empowerment, personal growth and development, and establishment of limits and achieving balance. The notion of empowerment arose from the discussion on expectations. There was consensus among interim chairs regarding their understanding of the broad, overarching expectations of the interim chair position. However, many participants expressed concerns about their lack of clarity regarding specific charges or tasks. One interim chair commented: “there was no chair's manual in the top desk drawer to guide my day-to-day activities.” The interim chair group stressed the importance of establishing clear expectations from the dean before committing to serve. Armed with a clear understanding of their intended role, interim chairs should feel empowered to act with the full authority of their position to achieve the mission of the department. This action included making difficult decisions regarding faculty recruitment and retention, budget allocations, and so forth. All of the participants in the focus group acknowledged the valuable learning experience gained by serving as interim chair. One interim chair remarked: “once you're in the role, you're in the role immediately so you have no choice but to learn the job quickly.” The steepest learning curves were in the areas of budget/finance and dealing with faculty. The interim chairs discussed the importance of establishing limits and striving for balance in their professional and personal lives. The interim chair job is demanding and requires a significant commitment of time and effort. These demands can become overwhelming. One interim chair described his admission to the hospital for congestive heart failure during the final days of his interim chair service. Another commented that although she had excelled throughout her career by simply doubling her efforts, this approach was impossible as interim chair because of the tremendous increase in her work responsibilities. She was overwhelmed and stressed by her desire to “do it all and do it all well.” Finally, the participants encouraged interim chairs to adjust their patient care, research, education, and administrative duties to accommodate their new leadership role. One interim chair reflected on advice he received from the dean at the time of his appointment: “deciding what not to do is equally, if not more, important than deciding what to do.” Leadership in schools of medicine is demanding. Deans, vice-deans, associate deans, department chairs, and division chiefs play important roles in the day-to-day operation of these increasingly complex organizations. Although fulfillment of the traditional academic missions of teaching, research, and service is expected, successful operation of a multi-million or multi-billion dollar clinical enterprise is another expectation that is not usually encountered in other academic disciplines. The leadership skills and personal characteristics required are markedly different than in the typical academic setting.6Souba W.W. The new leaders: new demands in a changing, turbulent environment.J Am Coll Surg. 2003; 197: 79-87Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar, 7Grigsby R.K. Hefner D.S. Souba W.W. Kirch D.G. The future-oriented department chair.Acad Med. 2004; 79: 571-577Crossref PubMed Scopus (71) Google Scholar The changing health care environment and its impact on academic health centers have significantly influenced the requirements of department chairs. Greater emphasis should be placed on a leader's ability to learn and help others succeed rather than the candidate's national stature, institution of origin, or individual accomplishments. Competencies for today's department chairs include an understanding of the business of medicine, interpersonal and communication skills, the ability to deal with conflict and solve adaptive challenges, and the ability to build and work on teams.6Souba W.W. The new leaders: new demands in a changing, turbulent environment.J Am Coll Surg. 2003; 197: 79-87Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar These characteristics were reiterated and reinforced by the interim chairs participating in our study. Through the survey responses and focus group discussion, the interim chairs highlighted 5 themes regarding their leadership roles: empowerment, personal growth and development, communication, strategic planning, and limits and balance. Establishing clear expectations from the dean is an essential first step in accepting and fulfilling an interim leadership position.8Chapman J.E. Chapman J.J. Lostetter J.O. The acting or interim leadership position: expectations, perceptions, realities.Health Care Manage Rev. 1988; 13: 81-88PubMed Google Scholar Although many different interim chair roles have been described,9Sommer R. Models of departmental leadership.The Department Chair. 2008; 18: 5-6Google Scholar our cohort felt empowered to act rather than simply assume a placeholder role. Specific actions in the early interim chair period include developing a cohesive leadership team and identifying “quick win” opportunities to demonstrate leadership effectiveness. All of the participants in our study agreed that serving as interim chair was an invaluable learning experience. Much of the learning was derived from the relationships formed with mentors, fellow chairs, and senior administrators. The majority of interim chairs in our study developed meaningful, lasting mentor relationships they believed were critical to their development as leaders. Although chairs and senior administrators were eager to help and very generous with their time when asked, it was uncommon for prospective mentors to approach newly appointed interim chairs. Therefore, we encourage interim chairs to initiate and cultivate the mentor–mentee relationships. Serving as interim chair moves individuals out of their comfort zone and forces them to develop different skills sets. Interim chairs and chairs often are appointed because of what they have accomplished individually. In contrast, their leadership effectiveness is based on their ability to work with others. Delegating responsibilities to others can be a significant obstacle for new leaders simply because they have enjoyed great success doing things themselves; however, overcoming this challenge is an essential—and highly rewarding—component of the interim chair role. Although there are a variety of inherent personal qualities essential for success as interim chair (eg, honesty, integrity, fairness), many important skills regarding people and finances can be learned. Areas for instruction include negotiation; crisis management; mentoring of junior faculty; and budget and finances. We advocate for the development of structured educational programs specifically designed for interim leaders—both locally and nationally—to facilitate the acquisition of these essential skills. Specifically, we recommend active mentoring and coaching sessions to enhance the ability of interim chairs to deal with financial and budgetary issues that were identified as particularly challenging areas for our interim chair cohort. Strong communication skills are essential for leaders in academic medicine.5Betof E.H. Harrison R.P. The newly appointed leader dilemma: a significant change in today's organizational culture.Manchester Review. 1996; (reprint 96001)Google Scholar, 6Souba W.W. The new leaders: new demands in a changing, turbulent environment.J Am Coll Surg. 2003; 197: 79-87Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Our group of interim chairs stressed the importance of frequent and open communication with key stakeholders. Several interim chairs met individually with each faculty member of their department before or immediately after their appointment. All of the chairs held regular faculty meetings during their interim chair periods. Chairs may be viewed as architects and strategists, working with department members to set a course to achieve the patient care, research, education, and service missions. This role can be difficult for interim leaders because their position may be viewed as a temporary “placeholder” until the “real” chair is identified. At times of transition, it can be helpful to take an honest look at the department's strengths, weaknesses, opportunities, and threats/obstacles and establish or revisit the department's mission, vision, shared values, and strategies. Interim chairs can use this activity to redirect the department from the negativity that often pervades a time of transition to a more future-oriented time of growth, development, and productivity. Finally, interim chairs must consider the importance of limits and balance as they assume their new leadership roles. Leadership within academic departments is demanding and leaders can become frustrated and overwhelmed. Adjusting day-to-day work responsibilities, actively deciding what to do and not do, regularly seeking guidance and support from mentors, not personalizing difficult situations, and balancing personal and professional responsibilities are effective ways of reducing the risk of burnout in the interim chair role. Our study has several limitations. The results are generated from a small number of interim chairs from 1 institution. All were appointed by a single dean and may have been selected to serve as interim chair on the basis of similar skills sets and attitudes. It is unclear whether these findings are transferable to other academic health centers. Two of the authors served as interim chairs and participated in all aspects of the study, potentially biasing the results and conclusions. The online surveys were completed anonymously so the authors were not able to differentiate between the responses of interim chairs of basic science and clinical departments. The study did not take into account the duration or status of interim chair service. Academic health centers regularly experience turnover of department chairs. Interim chairs are being appointed more frequently, serving for longer periods of time, and increasingly assuming permanent chair positions. Armed with clear expectations from the dean, interim chairs are empowered to act to achieve the department's mission. The interim chair experience provides a unique learning opportunity; interim chairs are encouraged to use this experience to enhance their leadership abilities along with their knowledge and skills regarding people, budget, and finance. Communicating effectively, being available, and meeting regularly with key stakeholders are essential to the success of interim leaders—especially during times of transition. Finally, establishing limits and striving for balance in one's professional and personal life reduce the risk of burnout and increase the likelihood that the interim chair period will be characterized by tremendous growth and fulfillment.