A Call to Leadership

Academic family medicine faces an impending leadership crisis,^1-4 embodied by a deficit of available applicants for vacant chair positions nationwide. The most recent data from the Association of Departments of Family Medicine (ADFM) that includes most allopathic departments of family medicine in the United States, and a number of osteopathic departments, large academic medical center departments, and some Canadian departments of family medicine, suggests that about 25% of family medicine chair positions (42 of 158 member departments) remained unfilled as of summer 2022.⁵ Compounding this, a 2021 Association of American Medical Colleges (AAMC) survey documented that department chairs are 10 years older compared with 1977,⁶ and with the average age of clinical department chairs being 59.4 years, potential retirements of an aging workforce may further exacerbate this shortage.⁷ In a 2021 ADFM survey of the family medicine chairs, the majority (85%, 56/66 respondents) reported that they did not seek the chair role in their career before they became the chair.⁸ This prompted the ADFM’s Leadership Development Committee to study and address this leadership vacuum in family medicine.

Leadership and the Role of the Chair

The chair role defines strategy, shapes the culture, develops people, and promotes a shared vision that is greater than the sum of its parts.⁹ As full-time leaders, chairs must leverage their strengths, while employing faculty with complementary expertise in research, education, and administration to forge a balanced team. Chairs prioritize a comprehensive mission and work to effectively manage inevitable conflicts between the academic and clinical missions.¹⁰

The role of the department chair has changed in recent decades,^11-13 and most department chairs felt “ill prepared to succeed in this difficult leadership position.”^14-15 However, as Souba wrote in 2004, “Leadership is created in and emerges from the relational space that connects people—accordingly, leadership development involves building high-quality connections between people.”¹⁶ Building relationships represents a core family medicine skill that can be utilized to cultivate a leadership workforce—and a large pool of mid-career faculty and clinically practicing family physicians often have the foundational skills necessary for success. Reorienting the perception of academic leadership from one of hardship to a more enticing, more functional, and rewarding career move is imperative.

However, significant barriers exist for that goal. These include a shortage of primary care physicians, difficulty in recruiting, retaining, and promoting primary care faculty,¹⁷ attrition of faculty, a challenging work-life balance, and the costs of recruitment.^18,21 A 2015 survey of internal medicine chairs documented that leadership searches took 7 to 9 months with a shortage of qualified candidates being the key barrier.²² One may assume the combination of the COVID-19 pandemic, senior leadership retirement, burnout, and unaddressed systemic bias and racism serves only to deepen the leadership void. Women and underrepresented in medicine (URiM) individuals in particular may underestimate their leadership potential, despite high achievements.²³ Improved mentorship and sponsorship for these groups will prove essential to overcoming this barrier within the pathways that exist toward leadership roles.^24-25

The Council for Academic Family Medicine (CAFM) Leadership Development Task Force identified 4 dominant leadership domains that exist in academic medicine. These pathways include clinical, undergraduate and graduate medical education, and research.²⁶ Experience and skills development may also be gained by local and national committee work, advocacy, quality improvement, community service, and other roles that reflect critical thinking and building relationships to achieve goals.²⁷ In a 25-year longitudinal study of science, technology, engineering, and mathematics (STEM) graduate students, those that advanced to higher leadership positions (ie, chairs, CEOs, etc.) possessed greater levels of interpersonal presence, finished tasks independently, and favored career growth choices over other activities.²⁸ Women and URiM individuals also have a greater diversity of outside interests that lend themselves to leadership roles.²⁹ Recognizing qualities such as these in medical students and residents, in particular, may foster potential and interest in future leadership roles.

A Call to Leadership

As noted earlier, most family medicine department chairs did not purposefully pursue that leadership role but accepted the role based on their acquired skills, experience, and relationships. Even ambitious leaders face challenges and barriers that may impede successful leadership transitions. Insufficient training, clinical demands, organizational conflict, and confounding culture challenge anyone in the chair role. Voices calling for continued leadership training, by whatever pathway, continue to grow, to inspire those to seek out the role as an academic medicine leader.^30-33

This committee asks the community of academic family medicine to embrace a leadership identity, share rewarding experiences of leadership and encourage others in our networks to embark on a leadership path. Regardless of someone’s starting point, when considering leadership positions, reviewing the position description for responsibilities and time commitments should provide insight into the demands, complexity, and needs of the role. We have created core leadership competencies for academic leaders to assist in assessing one’s strengths and developmental needs for higher leadership.³⁴

The demand for leadership within our discipline is not unlike society’s need at our beginnings in 1969. Then, as now, challenges exist requiring a response. Navigating a global pandemic, widening disparities in health, and climate change, with fewer US medical student graduates applying to family medicine residencies, demands leadership. Candidates from a broad range of backgrounds and skills within family medicine are needed to fill the department chair vacancies and other leadership positions within our discipline. A variety of pathways exist that capitalize on the strengths of family medicine—relationship building, empathy, critical thinking, and attunement to context and systems—to serve in leadership roles. Please apply and encourage others to join in the leadership journey.