ASSESSING THE POSTION: WHAT I HAVE LEARNED True Confessions of an Itinerant Chair

1. ASSESSING THE POSTION: WHAT I HAVE LEARNEDTrue Confessions of an Itinerant Chair Raymond C. Roy, Ph.D., M.D. Professor & Chair of Anesthesiology Wake Forest University School of Medicine Winston-Salem, NC, USA rroy@wfubmc.edu

3. PRE-CHAIR HISTORY

4. PERSONAL BACKGROUND • 1970 – Father-in-law medical role model • loved internal medicine, loved his “job” • 1971 – PhD lessons • some problems take months to years to solve • lab research ≠ clinical research ≠ clinical work • 1978 – 1st time acknowledged goal • when PGY2, told Visiting Professor Ted Eger aspired to chair academic anesthesia department • surprised myself

5. PERSONAL BACKGROUND • 1980’s – “magical experience” as part of team building “top 10” academic department • “critical mass” of colleagues with high expectations • all trained in programs with strong academic culture • most recruited by “unheralded” Chair, Tom Irving • 9 of us became academic chairs • Butterworth, Gravlee, James, Johnston, McLesky, Prielipp, Prough, Roy, Stullken • smooth succession: Tom Irving to Frank James

6. PERSONAL BACKGROUND • 1987-’92 – Vice chair lessons • “no” actually means “not now” or “not as presented” • “yes” more likely if problem and solution(s) identified • mission-based budgeting “hoax” • academic costs (research, teaching, faculty development, administration) > academic revenues (endowments, annual funds, Medicare, grants) • culture critical: department members must be willing to use clinical revenues to support academics and to accept lower salary in exchange for time & resources • desired salary ratio: private:academic < 2

7. CHAIR HISTORY

8. MUSC – 1992-’96 • Replaced “liked” chair of > 20 yrs • retired completely • “zeroed” accounts with exit bonus to each “partner” • Strong dean who was strong mentor • Critical mass of faculty members with academic potential • Weak package • Salary: department 100% • 2 chair training courses (AAMC, Harvard)

9. MUSC – 1992-’96 • Cultivated surgery chair as ally • Quickly addressed his OR concerns • His star NIH-funded researcher mentored us • Consultant for 360o appraisal in 2nd year • Vice chair issues

10. Dean as Mentor –What I Now Expect from a Dean • Clear goals & markers of success • Provided $ for non-clinical activities when reasonable plan submitted • Accessible for one-on-one discussions • explained Δ: negotiating with “my own” $ (i.e., departmental) versus negotiating for new $ • accurate assessments & honest appraisals • placing “my stamp” on MUSC anesthesia by staying vs. using MUSC as stepping stone • 1992: promised wife I would apply for WFU Chair (return to Winston-Salem) if position available before I turned 55

11. Why did I leave MUSC for UVA? • MUSC departmental plateau • academically almost as far along as I felt it could be with people and resources available • my 4 yrs still the best 4 academic yrs in their history • consolidating phase of grow, consolidate, grow cycle • new chair had no immediate problems to address • succession – reasonable in-house candidates • Personal issues • “needed” more academics (UVA > MUSC) • thought Frank James would retire at WFU at age 65 (not 62 when he did) when I would be 57

12. UVA – 1996-’98 • Replaced “respected & feared” chair of > 20 yrs • golden parachute > $1 million (over several yrs) • special office space • Ineffective dean • too interested in his own research, inaccessible, ignored clinical mission • Excellent faculty • Weak “package” • “Distinquished Chair” > 50% salary

13. UVA – 1996-’98 • “On my own” for 1st time • had not yet solved administrative structure • not yet mature enough to “self-mentor” • found maintaining strong department insufficient goal, i.e., needed to work toward something • chronic pain clinic • unsuccessful attempt to convert $$-losing classic model to “entrepreneurial” model • energy sapping culture clash

14. Why did I leave UVA for WFU? • Promise to my wife in 1992 • despite promise, initially said “no” to WFU • “Equivalent” academic culture • UVA department “reasonably” stable • no projects that “required” me to be there to finish • succession: excellent in-house candidates

15. WFU – 1998-2005 • Replaced “respected” chair • Sabbatical → GME Dean → retired completely • Good package • AIMS, patient simulation lab, discretionary fund • Salary: 50% hospital, 50% dept • Comfortable with WFU administrative structure • more able to make decisions and act than at UVA • stronger relationship with leaders than at UVA • “self-mentoring”

16. WFU – STRONG ACADEMICS • “Top 5” • 1 of about 20 who claim to be top 5 • Goal: #1 Anesthesia Teaching Residency • Top 10 in publications • > 100/yr x 5 yrs • 18th in NIH funding • $2,306,080, MD (5) > PhD (3) • Medical students • Mandatory 3rd yr week, elective 4th yr month • 18/108 entered anesthesia in ‘05

17. WFU – STRONG ACADEMICS • Strong Faculty • ASA: refresher course lecturers: 7 (’04), 6 (’05) • ABA: 8 oral examiners + 2 former directors • New Editor of Anesthesiology (Eisenach) • APSF Newsletter Editorial Office • Active external and internal websites • Outside OR clinical strengths • One L&D unit in area (7000 deliveries), PICU, adult ICU, TEE for residents, regional anesthesia & acute pain, successful private practice chronic pain model, preoperative assessment center (70-80 patients/day)

18. Examples of “Opportunities” at WFU • Faculty • other chair hires vs. new hires, #’s, specialization • Contracting • 3rd party payers, practice plan, hospital • Chronic pain clinic • Successful privatization (strong resident rotation, strong fellowship) • CRNA issues • Hospital employs, helps residency (enables regional anesthesia rotation, decrease call burden, relief for conferences/breaks)

19. Examples of “Opportunities” at WFU • Regional combined with acute pain • Sedation by non-anesthesiologists • Pediatric (pediatric intensivists), ER, Endoscopy, cardiology, procedure rooms (CRNA’s) • # trainees • ↓’ing # residents • ↑’ing # fellows • Anesthesia Information Management System

20. Examples of “Opportunities” at WFU • Preoperative Assessment Clinic • Quality & practice improvement • Pay for performance • Practice improvement (MOCA) • Evidence-based practice • Faculty development • Academic medical center administration • Evidenced-based practice • Simulation-based CME

21. REASONS NOT TO SEEK ACADEMIC CHAIR • Personal prestige • “faster track” to full professor • “launch pad” for personal projects • Money • Escape • restlessness or disgruntlement • working too hard • tired of clinical work or call • loss of confidence in clinical ability

22. Personal Qualities that Make It Hard to Succeed as Chair • Inability to make tough decisions • fear of criticism, bad publicity, being blamed for failure • Act in untimely manner • act too late because fear uncertainty or criticism • act impulsively with too little planning or information • Inability to confront people • who are performing below standards, blocking efforts • Inability to accept “pace of change” • cannot accept current system while creating higher standard one

23. Personal Qualities that Make It Hard to Succeed as Chair • Do not know when or what to compromise • Easily depressed or discouraged • require a lot of positive feedback • Cannot accept interest hierarchy: corporate > department > personal • Jealous or arrogant • take credit from rather than give credit to the people you appoint, fear competition • Impatient, prone to anger, “thin skinned”

24. EMOTIONAL INTELLIGENCE • Sine qua non for leadership • You can have 1st class training, incisive mind, endless supply of good ideas, but still not be good leader • Self-awareness, self-regulation, motivation, empathy, & social skill • Understanding your own & other people’s emotional makeup well enough to move people in direction of accomplishing department’s & institution’s goals.

25. REASONS TO SEEK ACADEMIC CHAIR • Believe in the academic missions • Enjoy being part of a winning team • Like being involved in big projects • Feel joy in enabling, facilitating, mentoring the success of others

26. WHAT DO I THINK DEANS EXPECT? • Corporate > department view • within limits • Clear vision and plan for department • within context of institution’s strategic plan &resources • Problem solvers, not problem dumpers • Collegiality, professionalism, energy & enthusiasm

27. How high do you or your faculty members climb the “C (See)” ladder to help solve problems? Closerimplements & debriefs Constructerdevises solution Cogitater clearly defines problem Coper Works around problem Criticizerdefines what is wrong Complaineraware something not right

28. SUGGESTIONS • Recognize academics is chair with 4 legs • clinical, teaching, research, administration • poor administration can topple chair • Most important job is recruiting “high C” people and delegating well • double threats more likely than triple or quadruple • Strive to make yourself “non-essential” • create a department that functions well without you • identify and mentor potential successors • You could become disabled acutely

29. SUGGESTIONS • Expect to be judged on what your department and its members do • not on what you do personally • outside projects can be distractions • be careful what you say yes to do • Do not underestimate power of passive aggressive behavior • need bottom-up buy-in for “orders”, projects • you’re not a leader if cannot convince anyone to follow you.

30. SUGGESTIONS • Strive for clarity • in identifying and presenting problems and solutions • Avoid “bad-mouthing” • “create a culture” that will make it more difficult to address the reason in the future • “To speak ill of others is a dishonest way of praising ourselves.” Will Durant • Work with & for people you like, respect, & trust • Do not make the job so important that you’ll do anything to get it or keep it

31. Personal Notes • When you become chair at a place where you were a faculty member, your relationship with former colleagues is no longer an equal one • You might have to discipline or fire them • At dinner, do not sit down first at a table. Wait and sit next to someone