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ORIGINAL RESEARCH |
From the 1Departments of Obstetrics and Gynecology and 2Mathematics and Statistics, University of New Mexico, Albuquerque, New Mexico; 3Departments of Obstetrics and Gynecology at Oregon Health Sciences Center, Portland, Oregon; 4St. Louis University, St. Louis, Missouri; 5University of Texas-Galveston, Galveston, Texas; and 6Albert Einstein School of Medicine, Bronx, New York.
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ABSTRACT |
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METHODS: A database of appointment dates and tenure of chairs at each of 125 Association of American Medical Colleges–approved United States medical schools was collated using membership listings from the Association of Professors of Gynecology and Obstetrics and from the Council of University Chairs in Obstetrics and Gynecology. Complete data from 118 departments were confirmed by selective correspondence at individual departments and further review by the investigators.
RESULTS: A total of 260 individuals (232 men, 28 women) became new chairs between 1981 and 2005. The annual turnover rate increased gradually from 6.0% to 12.7%. Five-year net retention rates remained steady between 1982 and 1997 but dropped after 1997 (85.6% compared with 63.2%; P=.03). A chair's tenure ranged widely (1 to 23 years; median 8 years), regardless of gender or school type, size, or location. Approximately one half of interim chairs became permanent chairs, usually at their own institution. The number of new women chairs increased from none in 1981 to 17 (15.2% of total chairs) in 2005.
CONCLUSION: Academic chair positions in obstetrics and gynecology experienced a doubling in annual turnover rates, while retention rates declined. The proportion of chairs occupied by women increased progressively.
LEVEL OF EVIDENCE: II-2
In addition to negotiating stresses faced by all clinical chairs, those in obstetrics and gynecology must provide leadership and direction for challenges unique to our discipline. Challenges include litigation risks that are higher than before, burdens of undergraduate education in preclinical and clerkship training that are similar to larger departments, and faculty wanting part-time positions that can create difficulties in developing career pathways. In addition, fewer U.S. medical students are willing to pursue careers in obstetrics and gynecology due to the potential of litigation, decreased reimbursements, and the continued demanding lifestyles they perceive for our discipline.
The tenure of academic chairs in obstetrics and gynecology has heretofore not been previously reported. The objective of this longitudinal investigation was to examine the turnover and retention rates of these chairs between 1981 and 2005. By evaluating trends, issues about academic leadership will be better understood and, we hope, better addressed for the future.
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MATERIALS AND METHODS |
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The second phase consisted of direct correspondence (either electronic mail or telephone) with the academic department for clarification of data. The department chair or administrator verified or corrected the years of service of the chair and whether the chair was permanent or interim. The third phase consisted of each investigator reviewing all listings of chairs (permanent or interim) for final confirmation of completeness and accuracy. The investigators themselves served from 8 to 25 years as chairs and are all officers of the Council of University Chairs in Obstetrics and Gynecology organization.
For this survey, we selected a 25-year period (1981 to 2005) of investigation. The duration of this period permitted us to better assess trends in turnover rates and to more reliably determine net retention rates. Furthermore, our initial review disclosed the longest tenure of any active chair to be 25 years.
Several terms were defined for consistency in reporting. Academic chairs were those at U.S. medical schools as listed by the Association of American Medical Colleges. An annual turnover rate was defined as the number of new chair positions that became available from the total chairs in one year. The net retention rate was defined as the percentage of new chairs retained at their institution over a period of time. We chose 5 years as a period to examine retention rates because of its common use as an industry standard. An interim chair was defined, for purposes of this study, as any person who led the department for at least one calendar year between former and new permanent chairs. This minimum period was chosen because it was otherwise difficult to discern the name and the duration of an interim chair. The year in which the new chair began was the year in which she or he assumed office rather than when a verbal commitment was made.
All data were entered into a SAS/STAT 9.1 package (SAS Institute, Inc., Cary, NC). The data were reported as a means±standard error of the mean, median, or percentage. Statistical analysis consisted of the two-tailed Student t test, F test (one-way analysis of variance), and Fisher exact test where appropriate. A P value less than .05 was considered to be statistically significant.
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RESULTS |
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Figure 1 displays annual department turnover rates of chairs in obstetrics and gynecology. The turnover rate increased gradually from 6.0% to 12.7% between 1981 and 2005. No known national event was found to correlate with the year-to-year variation. This "doubling effect" was unaffected by medical school size or whether the institution was public or private. The typical department had two new chairs during this 25-year period, whereas it was less common to have fewer than two (22.9%) or more than three (8.5%) new chairs per department (Fig. 2). None of the nine districts of the American College of Obstetricians and Gynecologists (ACOG) was more likely to see a significantly higher turnover rate of chairs.
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Twenty-eight (11.1%) of all new chairs were women. As shown in Figure 3, the percent of chairs as women increased from none in 1981 to 17 (15.2%) in 2005. All women were preceded by men as chairs, whereas six men who became new chairs were preceded by women. The duration of tenure as chair of a department was not different for women than for men (7.8±0.4 years compared with 7.8±1.5 years, P=.96).
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During the period analyzed, there were 254 turnovers. Interim chairs who served for at least 1 year were found in 110 (43.3%) instances. The longest term of an interim chair was 8 years. Half of all interim chairs became a permanent chair after 1988 (1981–88: 7 of 34, 20.6%; 1989–96: 19 of 39, 48.7%; 1997–2004: 18 of 36, 50.0%). Most who later became permanent chairs remained at their institution, while few became a chair elsewhere (7 of 110; 6.4%).
Figure 4 displays 5-year net retention rates. No significant differences in retention rates were observed during the periods between 1982–1988, 1986–1989, 1990–1993, and 1994–1997. In contrast, the 5-year retention rate declined significantly (P=.03) from 85.6% between 1981 and 1997 to 63.2% between 1998 to 2001. Less than half of the new chairs remained in their position for at least 10 years (42.7%) and much fewer for 15 years (15.1%). A very short retention period (2 years or less) was quite uncommon (3.2%). A short retention period (4 years or less) was more common beyond 1997 than before (24.3% compared with 9.2%, P=.03).
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DISCUSSION |
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Several reasons, alone or combined, explain voluntary or involuntary departures of chairs. Categories for dismissal include misbehavior, scientific misconduct, mismanagement of funds, and conflicts of interest or personality.3 Sometimes chairs make (or do not make) tough decisions, and their department develops factions opposing the chair's continued tenure. Some chairs bring controversy and eventually lose credibility. Other reasons to resign include desires either to return to academic or clinical careers or to avoid the constant stress that affects a chair's health or ability to work effectively. On the positive side, a chair who is able and whose record is strong as a scholar or administrator or both may leave to assume a deanship or another administrative position.
How long is an appropriate tenure for a chair? It depends on that individual's success and job satisfaction. The tenure is now shorter because of constraints that are more evident. Chairs who feel that they performed maximally and who now cease to find reward in doing their job may leave because of burnout. This syndrome is characterized by emotional exhaustion, depersonalization in relationships with coworkers or clients, and a sense of inadequacy or reduced personal accomplishment. Gabbe et al4 reported in 2002 on the prevalence of burnout in chairs of academic obstetrics and gynecology. Responses to questionnaires came from 119 chairs, who served for an average of 7.2 years. The most significant stressors were hospital and departmental budget deficits, Medicare and Medicaid billing audits, loss of key faculty, union disputes, and faculty, resident, and staff dismissals. This creates an almost overwhelming challenge for a department to survive. Burnout was more common in new chairs. High emotional exhaustion was observed in younger chairs, those who worked nearly 70 hours each week, and those whose spouse or partner was less supportive.
A warning from this study should be sounded about the recent decline in retention rates of chairs and its effect on the well-being of a department. A chair remaining in his or her current position may not necessarily be good. We observed that only a very small proportion of current chairs began 10 or 15 years ago. In contrast, the burden with frequent leadership changes is felt not only by departmental faculty but also by chairs of affiliated hospitals and medical schools. A reduction in the retention rate of chairs, as observed here in recent years, often creates departmental instability. Replacement requires significant faculty time and institutional resources. Organizational dysfunction resulting from chair turnover also has a potential negative effect on women's health care in general, because it involves leaders responsible for the education of medical students and residents.
Several solutions in replacing a chair are worthy of consideration. New leaders often require early coaching or mentorship to prepare them for balancing the multiple roles and varied stresses of the position. We believe such mentorship to be a prime responsibility of those engaged in successful academic leadership. Another option would be to choose and empower a qualified set of vice chairs to carry out the department's mission. As another solution, certain chairs may comprise more than one position (academic chair, clinical chair). A chair position could be rotated among strong senior faculty who have demonstrated leadership skills and a business sense.
It is encouraging that the number of women serving as chairs increased in the past decade. This trend coincides with a growing presence of women in residencies and in the workforce of obstetrics and gynecology. Unfortunately, the growth in women promoted to professor, a critical step in leadership development toward chair positions, has not increased proportionately to the growth of female residents and junior faculty.5 This lack of a proportional increase suggests that we may not adequately mentor and retain female talent in academic departments of obstetrics and gynecology. A lack of interest in assuming the role of department chair may be more inherent among women. In a survey of professional women, those age 28 to 40 showed high levels of being very ambitious (57%) whereas only 37% of older women were very ambitious. Keys to retention involved achieving the experiences needed for leadership and receiving recognition for a job well done. Given the gender distribution of medical students and of obstetrics and gynecology residents and faculty, this proportional lack of women as department leaders needs to be scrutinized with a greater emphasis on identifying and nurturing women as leaders.6 It is important to note, however, that creating an environment that recognizes achievement should assure that we also foster the careers of qualified men as leaders for our discipline.
We did not examine in detail whether the chairs were recruited internally or externally. Interim chairs were chosen internally, and since 1989 one half of interim chairs studied here became permanent and usually at their own institution. Furthermore, it was not possible in this long-term study to determine whether the new chair was a generalist or subspecialty board–certified. Bates and Blackhurst7 reported in 1992 that 62% of chairs were subspecialty board–certified (27% maternal–fetal medicine, 19% gynecologic oncology, 16% reproductive endocrinology). Our impressions in recent years support findings by Gabbe et al,4 who demonstrated in 2002 that three fourths of all current chairs are subspecialists. Most trained in maternal–fetal medicine (43%), followed by gynecologic oncology (17%) and reproductive endocrinology and infertility (16%). There did not seem to be a strong relation between eventual burnout and the chair's subspecialty certification. This continuing increase in subspecialists who become department chairs stands in stark contrast to the low proportion of all certified obstetrician–gynecologists who pursue subspecialty certification (4.5%).6
In summary, these past 25 years demonstrated unprecedented reforms that steer our complex organizations in multiple, competing new directions. In an academic organization, the departmental chair is usually the linchpin, and therefore often bears the most stress.8 Historical conditions that previously allowed a chair to thrive in an era of ever-expanding resources, unbridled growth, limited competition, and limited public accountability are now replaced by constrained resources, right-sizing, fiercer competition, and increasing federal and public scrutiny. In recognition of these stresses on department chairs, Council of University Chairs in Obstetrics and Gynecology is searching for ways to assist academic chairs in conducting their multifaceted and often conflicting responsibilities. The most popular and best attended aspect of the annual Council of University Chairs in Obstetrics and Gynecology meeting is the "School for New Chairs" in which mentoring and coaching are encouraged. This council is also assuming a role of identifying and preparing potential chair appointees for eventual successful leadership. These efforts, in conjunction with the Association of Professors of Gynecology and Obstetrics, will attempt to better address environmental factors as the turnover of obstetrics and gynecology chairs continues to be closely scrutinized.
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Footnotes |
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Corresponding author: William F. Rayburn, MD, Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, MSC 10 5580, 1 University of New Mexico, Albuquerque NM 87131; e-mail: wrayburn{at}salud.unm.edu.
doi:10.1097/01.AOG.0000240140.27246.93
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REFERENCES |
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2. Pearson J, Ibrahim T, Association of Professors of Medicine. Turnover among APM members since 1971. Am J Med 2002;113:706–710.[Medline]
3. Biebuyck JF, Mallon WT. Why chairs leave—or lose—their jobs. In: Association of American Medical Colleges. The successful medical school department chair: a guide to good institutional practice. Washington (DC): Association of American Medical Colleges; 2003. p. 39–47.
4. Gabbe SG, Melville J, Mandel L, Walker E. Burnout in chairs of obstetrics and gynecology: diagnosis, treatment, and prevention. Am J Obstet Gynecol 2002;186:601–12.[Medline]
5. Hewlett SA, Luce CB. Off ramps and on ramps, keeping talented women on the road to success. Harv Bus Rev 2005;83:43–6.[Medline]
6. AAMC. The changing representation of men and women in academic medicine. Available at: http://www.aamc.org/data/aib/aibissues/aibvol5-no2.pdf. Retrieved August 10, 2005.
7. Bates GW, Blackhurst DW. Leadership qualities of obstetrics and gynecology department chairmen of United States medical schools. Am J Obstet Gynecol 1992;166:1102–11.[Medline]
8. Cohen JJ. Who thought sitting in a chair would be so hard [editorial]? Acad Med 1998;73:284.
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