As I’ve noted elsewhere, I started this blog in the Spring of 2023. I was on my self- imposed (and -funded) sabbatical after nearly three years as the chair of radiology at USC. I haven’t written about that particular experience so far. When I heard that the dean who had been at USC when I left (my direct supervisor, as it were) had stepped down, it seemed as good a time as any to reflect on my time there.
Why does anyone want to be a chair? This was a vexing question then, and perhaps even more so now in retrospect. I’m pretty sure I had a good answer when I was interviewed (over and over and over again) for the USC job. If someone asked me now, I’d say that being a chair means building an organization that people trust, and that people believe in. That the organization helps its individuals realize their potential that they might not otherwise realize. The chair’s job is to build trust, build the organization, and inspire the folks who make up the organization. Simple, right?
There are several elements to the chair’s job: clinical operations (keeping the trains on the track, and running on time, while building more track, so to speak), educational mission (making sure you offer a rigorous and comprehensive training program across all levels of learners), scientific inquiry (building and investing in intramural research programs, and facilitating extramural collaborations, not to mention maintaining a robust but nimble research infrastructure), academic promotions (ensuring that faculty have a path forward to becoming professors), philanthropy (an increasingly important source of support for all of the above missions), and about 20 other dishes you’ve got to keep spinning at given time, not to mix metaphors. It is a hard job.
Here’s the most frustrating part: chairs are now effectively middle managers at best. During the rise of consolidated faculty practices and academic medical centers (systemization), the autonomy that chairs used to have has been eroded substantially. There are still a few places where chairs continue to exert more control over their fiefdom, but they are increasingly rare. Most medical schools don’t have substantial funds- they are reliant upon “funds flow” from the hospital (who grudgingly share technical revenue from imaging services, with all kinds of strings attached). Again, there are some places that have preserved their independent revenue streams better than others. But for the most part, these places are becoming unicorns.
So chairs are given mandates, without real control. It is, in many ways, a recipe for frustration, if not disaster. My fights with the “powers that be” weren’t really fights. It was like a 3 year-old flaying his arms around, while an adult easily holds him at bay with a firm hand on his head. All chairs advocate for what their department needs (17 of them at USC). What does the radiology department need in this year’s budget? A new MRI? A dual source CT? PET MRI? Maybe the system decides they’d rather support the expensive recruitment of a prized orthopaedic surgeon who is going to significantly drive OR volumes (and, therefore, hospital revenue). Radiology can do without a new MRI for another year, or two, maybe three. They can justify it by saying that the images that these old machines aren’t the best, but they’re “good enough.”
The faculty can’t do their research on “good enough” images- they are dependent on contemporary imaging equipment. They can’t build the collaborations they need to sustain their work. And if they can’t do research, they can’t be promoted. And they’re frustrated teaching the residents on antiquated imaging platforms. The faculty feel like they're handicapped- how can they do a good job with outdated imaging equipment? The implicit message is that radiology isn’t important to the system. “Good enough” is good enough. It is not surprising that faculty might look elsewhere to a system that values them.
Is this what happened to me at USC? Maybe, sorta? I think some variant of these tropes happen to all chairs at all institutions. I think the key to be a successful chair is find the place where the system understands the value of people and imaging (in that order) and is willing to make an investment to that end. Maybe USC would’ve been more willing to invest in imaging but I started on May 1, 2020. Yes, in the middle of pandemic, when USC revenue dropped 30% overnight. That was a tough crater to crawl out of. I also misjudged the institution- I was never going to be able to do what I had envisioned there. I am an eternal optimist and I am trusting to a fault. I've learned that's my blind spot and the department suffered as a result unfortunately.
I wish I had been better equipped to deal with the circumstances into which I was thrust. I did my best. I lost a lot of sleep and my health definitely declined. But I have no absolutely no regrets and I hold no one more responsible than me for what happened (or didn't happen) there. I learned so much about modern healthcare, and me. I definitely learned that radiology is an alien culture compared with interventional radiology. The idea of keeping to increasingly disparate subspecialties together under the same house makes absolutely no sense. Anyone who thinks otherwise is either delusional or just not paying attention.
Well, this little reflection has been fun. I honestly don't think about those days very much. I got to work with some amazing people who I deeply respect. There were a few shady shitheels too but even though they suck up so much energy and oxygen in the room, the good people will always rise to the top. See, there's the optimist again!