Who wants to be a department head?

One of my very good friends, who is brilliant, committed, and immensely capable, was given the honor several years ago of being made head of his hospital clinical group. It appears likely that when he resigns there will not be anyone willing to take up his stead. It is a job that in modern settings puts a clinician in an almost untenable position of frustration, blame catching, impotent budgeting, and impossible group management.

Another colleague with an advanc­ed business degree tells me there is a defined difference between leadership and management. Leaders are supposed to motivate, inspire, and direct the progress of a group toward ideological goals they share. A manager, in distinction, plans, coordinates, and manages the practicalities of achieving those goals. 

I think in our present-day health care industry, those roles may not be in the best orientation. Re­gardless of the goodness, motivation, and business acumen of our administration and management colleagues, the flow of front-line driven medical direction toward the hand of management is often interrupted and in many cases completely reversed. 

In our organizational structure, the clinically active medical leadership is so far down the chart of real decision makers it is almost a falsehood to call it leadership. There is a person assigned to a “headship” role, but the ability to actually make meaningful decisions that “motivate, inspire, and direct progress” is often pre-empted by ad­ministrative managers in roles above. Clinical heads are asked to give input into staffing issues, equipment, education, hospital resources, site development, compensation, and wait lists. But they are really not in a position to make even close to a final decision or even prioritization. They also often must take the responsibility for the negatives of a different path someone else has determined their group must follow. I accept that no one group can have everything it wants considering the resource demands on the larger community, but frustratingly, even non-resource decisions seem to be treated this way. 

I don’t think it’s the people. It’s the culture and structure. The paths of communication are disconnected, shift­ed, and unequally powered. And there is so little trust and transparency in either direction that any perceived problems are magnified. So it often feels like big decisions are made autocratically in one silo and announced as faits accomplis to the people in another silo who live with the day-to-day consequences.

Meetings are difficult. A surgical division head just cannot be counted on to come to a meeting scheduled by managers at 11 a.m. on 2 days’ (or even 2 weeks’) notice if it falls on an OR day. And after meetings with all stakeholders in the room, where we think a group decision has been agreed upon, very commonly a different decision will be announced once the issue is brought to a higher level of management. 

I don’t think for a second that managers and administrators are malicious or incompetent. Unlike most doctors, they are trained in administration; they do their jobs well. I have many respected friends in administrative positions. However, those who are the most effective in helping us achieve good patient care are the ones with a more balanced and open manager/clinical leader relationship, and to help us they often seem to need to sidestep the mandated structure of reporting and decision making. 

In my opinion, the modern anatomy of our hos­pital organizational system doesn’t allow us to communicate with enough equality to consistently make fair decisions. In the past it seemed the practising medical leadership structure was closer to parallel with the administrative structure, and the decision-making positions met on a reasonably level playing field. Now, in our leadership structure, you have to go many levels down before you find an active clinician decision maker. And in the newer clinical headship contracts I have seen, the leadership component of the job is defined and remunerated as an administrative man­agerial position, answerable to administrative policy, and includes language about the head ensuring that the group follows administrative direction, not bringing clinical issues the other way. 

Which brings us back to the difficulty in convincing clinicians to take on headship roles. In my hospital for some years we had a long-term “interim head” in almost every department. Few clinicians see much value in taking on these so-called leadership roles. There seems to be very limited ability to make change or solve problems that they identify. And many of them see the role bring real harm to their practice, their health, their relationships with their administrative and clinical colleagues, and the happiness of their families.
And we all pledged to “first do no harm.”
—CV