In Academic Medicine, Chair Roles Are Changing — as Are Recruitment Packages

By Jeffrey A. Schroetlin

The successful academic medicine chairs of the past were internationally recognized scholars who would attract new faculty on the basis of their reputations, and on their ability to have free rein over their start-up funds. They operated in a medical school model that some would describe as “feudal” — that is, chairs acted independently and ran their departments essentially as isolated small businesses.

Today’s medical schools face tremendous pressures related to cost, accreditation, and federal funding for research. They are still managing the effects of the Affordable Care Act, wrestling with increasing competition for patient populations, and even weighing mergers with community health systems. This tidal wave of change has forced a growing number of schools to look for new ways to support departments, and for new kinds of chairs to lead them.

When negotiation figures can stretch into the tens of millions related to support for building clinical, research, and education programs, would-be chairs know the success of their tenure can depend heavily on how well they negotiate for resources before accepting the offer. Medical schools, however, are less willing, and less able, to support recruitment packages without clear strings attached.

What Deans Want
Collaborative, business-minded, financially astute, and able to live with ambiguity — these are skills in high demand for department chairs today in academic medicine. That each chair must also have a high h-index and multiple grants, while showing commitment to education and a track record of growing competitive clinical programs, means the bar has been set incredibly high.

As such when chair positions open up, more medical school deans are charging their search committees with looking for leaders first and foremost, inviting the possibility that potential shortcomings in research or clinical operations can be supported by a vice chair. In essence, they’re asking for committees to give them someone they can work with, and who will support the medical school’s institutional priorities.

Today’s matrixed models of authority (and budgets) mean chairs must not just be open to working across the institution, but proactive in doing so. Fortunately, there is a growing corps of physician leaders, motivated by the promise of value-based care, who embrace the expectations of the modern medical school department. They see how undergraduate and graduate medical training is evolving, and support models of care that require multi-specialty, patient-focused teams organized around disease groups. They recognize that translational and interdisciplinary research is the currency of the realm in order to secure extramural funding.

Within established departments, lines of authority are blurred. A chair of internal medicine, for example, can today find a sizeable portion of the department faculty being paid and directed by an interdisciplinary cancer institute, heart center, or transplant program, amongst others. And as new departments emerge — including biomedical informatics, population health, and medical education — they often pull faculty together across varied medical specialties. Some of the newer medical schools have also created clinical departments reflecting interdisciplinary models, especially around cancer and diagnostic medicine. Chairs may have more faculty with shared appointments.

The integration of faculty physician practices into the medical center has also meant a significant change in funds flow for departments, making the chair’s authority over budgets more complex. Departments may no longer be directing the clinical billing for their faculty, and figuring out what exactly any department “earns” against its expenses can truly be a struggle.

For the basic sciences, many institutions — and especially the public ones — are having to push the limits of tenure, as departments with rosters of under-funded faculty and aging research infrastructures are struggling to guarantee salaries for life. New chair hires are often given recruitment packages to bring on additional faculty, while needing to push existing faculty to levels of greater productivity (or out the door).

Negotiating with Nuance
All of these factors make negotiations more sophisticated and strategic for both medical school administrators and chair candidates. Take, for example, the recent recruitment of a surgery chair within an integrated academic medical center. “Integrated” in this instance meant that all departmental revenues were swept up centrally, and reinvestments into new programs were determined by a council of chairs, the dean, and the CEO of the affiliated medical center.

While commitments were made to shore up weaker divisions and to hire several new investigators, future investments would rely on the department’s and the medical center’s ability to meet its fiscal goals, on the new chair’s ability to maintain a strong relationship with the hospital and her fellow chairs, and finally her skill for creating sound business plans for new growth — something she certainly was not taught in medical school. The result was that she was offered a very substantial recruitment package, but one that would be doled out over time and which required ongoing collaboration.

In the midst of a changing healthcare landscape, medical school deans are forced to continually reevaluate priorities. Thus, static, five-year recruitment packages for departments are becoming increasingly hard to stand by. The best packages can be a working strategic plan for the department, outlining goals, how to measure them, and guaranteeing rewards for performance.

There are a few key trends shaping recruitment packages for new chairs… and in turn helping to define chair roles:

  1. Institutional success and departmental success are mutually dependent. Ongoing commitment of resources to departments can rely heavily on the institution being able to meet its strategic and financial goals.
  2. Departmental budgets will rely on incentivizing faculty productivity. New chairs are being asked to ensure that their ranks meet clinical and academic productivity metrics.
  3. Layered and contingent commitments are increasingly in play. If a chair is able to meet initial goals for performance and programmatic growth, additional, significant resources can be kicked in to fuel further growth while mitigating risk to the institution.

While many academic medicine departments still retain a feudal nature, the dynamics have shifted around recruiting and hiring new chairs and the packages they receive. As offers are negotiated, institutions and incoming chairs are wise to spell out commitments clearly, yet with the understanding that relationships — with the dean, with fellow chairs, as well as the affiliated medical center administrators — are what ultimately drive success.

This article was originally published by HigherEd Jobs. Permission to republish has been granted.