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Why Have So Few Radiation Oncologists Become U.S. or Canadian Medical School Deans or University Presidents?

2019; Elsevier BV; Volume: 103; Issue: 3 Linguagem: Inglês

10.1016/j.ijrobp.2018.11.010

1879-355X

Edward C. Halperin,

Radiology practices and education

There are 168 MD-granting schools of medicine in the United States and Canada.1Liaison Committee on Medical EducationFunctions and Structure of a Medical School: Standards for Accreditation of Medical Education Programs Leading to the MD Degree. Association of American Medical Colleges and American Medical Association, Washington DC2018Google Scholar None currently has a radiation oncologist as dean.2Association of Medical CollegesCouncil of Deans Directory. Association of Medical Colleges, Washington DC2018Google Scholar In the history of the United States and Canada, to my knowledge, 3 radiation oncologists have served as permanent (not interim) deans of a medical school: Samuel Hellman, MD, dean of the Pritzker School of Medicine, University of Chicago, 1988 to 1993; Allen S. Lichter, MD, dean of the School of Medicine, University of Michigan, 1998 to 2006; and Edward C. Halperin MD, MA, dean of the School of Medicine, University of Louisville, 2006 to 2012. Drs Hellman and Lichter also both served as president of the American Society for Clinical Oncology and Lichter also served as the society's chief executive officer (CEO). Hellman served as president of the American Society for Radiation Oncology. There are approximately 4100 colleges and universities in the United States and Canada. In the history of these countries, 1 radiation oncologist has served as permanent president/chancellor/CEO of a college or university: Edward C. Halperin, MD, MA, chancellor/CEO of New York Medical College of the Touro College (New York Medical College, [NYMC]) and University System, 2012 through present. New York Medical College, founded in 1860, is a health sciences university with schools of medicine, dentistry, nursing, health professions, and graduate studies. Radiation oncology is a recognized specialty of medicine, and the majority of U.S. and Canadian medical schools have academic departments of radiation oncology staffed by qualified faculty. Radiation oncologists interact with many other medical specialties and recognize that modern medicine is a “team sport.” In light of these facts, one must wonder about the paucity of radiation oncologists at the highest echelon of medical school and university leadership. The questions, therefore, that I wish to address are “Why have so few radiation oncologists become dean of the school of medicine or a college/university president/chancellor?” and “Does it matter?” I will offer 3 hypotheses in response to question 1 and some brief thoughts regarding question 2. The majority of the U.S. presidents were residents of states with relatively large populations at the time of their election: New York (7), Ohio (6), Virginia (5), Massachusetts (4), California (3), Tennessee (3), Texas (3), and Illinois (3). The 10 states with currently the smallest populations (Maine, New Hampshire, Rhode Island, Montana, Delaware, South Dakota, Alaska, North Dakota, Vermont, and Wyoming) have, collectively, produced 1 president (Franklin Pierce of New Hampshire). Politicians from a state with a larger voter base have a leg up in a national election. Similarly, one might argue that larger medical specialties are more likely to produce leaders of medical schools because the popularity of their specialty results in a comfort level among the deaconal search committee and faculty (Table 1). To the extent this is true, one would expect to see few radiation oncologists or, say, those in physical medicine and rehabilitation become dean—and neither specialty is currently represented.Table 1The medical specialties of deans of 168 U.S. and Canadian allopathic medical schools2Association of Medical CollegesCouncil of Deans Directory. Association of Medical Colleges, Washington DC2018Google ScholarSpecialty, including discipline's subspecialtiesNo.PercentageInternal medicine7042Pediatrics1710Family medicine127Psychiatry127Surgery117Radiology74Obstetrics-gynecology64Emergency medicine53Neurology53Otorhinolaryngology53Pathology53Anesthesiology21Ophthalmology21Neurosurgery21Urology21Double boarded21Oral maxillofacial surgery1<1Orthopedic surgery1<1PhD1<1 Open table in a new tab One assessment of medical school deanship was provided by Samuel Hellman:…the word dean is but one letter from dead… the only difference between being a dean and a practicing psychiatrist is that the dean's patients have tenure… most people will resent your taking credit [for your accomplishments]… the most disturbing social behavior in academic medicine is cannibalism. Mentors often eat their young, considering them a threat to their own position… The most obvious monster [in academic medicine]… is the hospital because of its size, finances, and organization. There is almost an inherent conflict between the goals of hospital administrative leadership and the purposes of academic medicine… empowered amateur members of the hospital board… believe physicians are incapable of grasping business principles but that they—the board members—are able to understand medicine… Donors… sometimes require the suspension of reason or taste… resist temptation of the initial offer of a deanship, even of an initial interview… allowing you to avoid the state of administrative purgatory.3Hellman S. A piece of my mind. Tales of the unnatural: Return from the dean(d).JAMA. 1998; 280: 1657-1658Crossref PubMed Google Scholar Although Dr Hellman would later refer to this essay as “light-hearted,” he continues to feel that it “is based on the real problems of governance in academic medical centers… A medical center must teach and do research, but it also must provide care.” A school of medicine “could not use maximizing the hospital's financial statements as a measure of our success. Responsible financial behavior was necessary but neither an appropriate nor sufficient criterion… The hospital administration and its board sometimes lost sight of the centrality of this mission, making reaching our goals more difficult.”4Hellman S. Learning While Caring: Reflections on a Half-Century of Cancer Practice, Education, and Ethics. Oxford University Press, New York, NY2016Crossref Google Scholar The distaste of university presidents, who generally come from a nonmedical background, for overseeing the medical school is exemplified by a very, very, old academic joke. Here is my version.5Gray H.H. An Academic Life: A Memoir. Princeton University Press, Princeton, NJ2018: 254-258Google Scholar A university president dies and goes to hell. The devil greets the president and tells him that he has a job all lined up for him. He is to be the president of the University of Hell. They walk through streets of souls burning in eternal damnation and, eventually, find themselves on a bucolic university campus. The grass is green, the students are happy, the library is full of scholars, the football team has had a winning season, and the faculty senate is in a good mood."That's it?" the president says. "You want me to be the president of the University of Hell?""That's it," says the devil. "Have a good time." The devil walks off, and the president surveys his new domain and is feeling pretty pleased with himself. The devil stops, looks over his shoulder, and says, “Oh, by the way Mr President, the University of Hell has 2 medical schools.” Perhaps, therefore, the reason so few radiation oncologists become deans is a conscious decision to avoid what is perceived as an undesirable job.3Hellman S. A piece of my mind. Tales of the unnatural: Return from the dean(d).JAMA. 1998; 280: 1657-1658Crossref PubMed Google Scholar, 6Wilson E.A. Perman J.A. Clawson D. Pearls for Leaders in Academic Medicine. Springer, New York, NY2008Google Scholar, 7Clayman R.V. The Compleat Dean: A Guide to Academic Leadership in an Age of Uncertainty. Ralph V. Clayman, Irvine2016Google Scholar, 8Levey G.S. Never Be Afraid to Do the Right Thing: A Leadership Guide in an Age of Change and Challenge. Second River Healthcare Press, Bozeman, Montana2011Google Scholar Over the past few decades, in spite of calls to the contrary, the number of radiation oncologists admitting patients to the hospital under their own name to an in-patient service has fallen.9Kligerman M.M. Gold medal acceptance speech: Comprehensive patient care in radiation therapy practice.Int J Radiat Oncol Biol Phys. 1983; 9: 1091-1092Abstract Full Text PDF PubMed Scopus (4) Google Scholar At many medical centers, even if the patient is being admitted to the hospital for brachytherapy or a complication of radiation therapy, the radiation oncologist is not the admitting physician of record. Some radiation oncologists do not do inpatient consultations by going to the patient's hospital room. Instead, they insist that the in-patient be brought to the radiation oncology clinic. “If they're not capable of traveling to my clinic on a stretcher, then they're not capable of getting external beam radiation therapy in my clinic,” they will say. It should be no surprise, therefore, that radiation oncologists who minimize their presence on the wards will not be viewed as “real doctors” by the other medical and surgical specialties. This attitude is compounded by the fact that as someone in an oncology discipline, the radiation oncologist may have little interaction with some of the nononcology specialists. When you add these behaviors to the fact that little or no radiation oncology is taught as part of the core basic biomedical sciences in the first 2 years of medical school, nor is it considered a core third-year medical school clerkship, it is to be expected that radiation oncologists are not viewed as part of the mainstream of the school of medicine and will be less likely to seek or be offered school-wide leadership positions. It is my experience that when a radiation oncologist applies for and is interviewed for a job as medical school dean or college/university president/chancellor, he or she better be ready for a cross examination and critique characterized by the following questions or comments I have heard during my career:•From someone in internal medicine: “Radiation oncology is a 4-year residency? Gee, I would have thought it only took a year to learn how to do that.”•When I first became the chairman of a Department of Radiation Oncology, the chairman of surgery referred to radiation oncology as a “clinical catfish: the bottom-feeding garbage-eater at the end of the clinical referral chain.”•From a search committee: “You have years of experience as a radiation oncology department chair? Well, it's not as if you've been chairman of medicine or pediatrics where you have been running a large and diverse department.”•From an interviewer: “Pediatric radiation oncology? That's your specialty? Such a small specialty, isn't it? Small. Very small.” (To which I replied, “What's small? The patients?”)•From a university president interviewing me for a dean's job: “Are you really prepared to make the really, really tough decisions? I'm not sure your experience puts you in the position to make really tough decisions. Can you really make hard decisions about promotion and tenure?” (I replied, “With all due respect, deciding whether or not to irradiate the brain of an 8- year-old with pontine glioma is a tough decision. Deciding who gets promoted to associate professor hardly seems in the same league.” I did not get the job.) The hurdles to overcome to be picked as dean will be followed by more substantial obstacles if the radiation oncologist seeks a job as university president or chancellor. When applying for such jobs, there will be a baseline discomfort with the idea of a physician as leader among members of the search committee who come from disciplines in the humanities, social sciences, and the law school. The comments, in my experience, will range from “How can you presume to understand our institutional culture?” to “The medical school at this university already has too much power. If the president/chancellor is a physician, it will just compound that situation.” Faced with repetitive questions such as “Can you understand our institutional culture?” I asked the late Edmund Pelligrino, an internist and the president of The Catholic University in Washington, DC, how he dealt with it. He told me that “No university in the U.S. awards the PhD degree in being a university president/chancellor. Everyone has to get out of their academic disciplinary comfort zone to become an administrator. In contrast to many other disciplines, at least physicians are trained to make decisions with incomplete information. Besides, look at how many lawyers become university presidents/chancellors. If they can do it, we certainly can.” Several universities have selected MDs as president/chancellor, including some institutions that do not have a medical school.10Altman L.K. The doctor's world; physicians join ranks of university presidents. New York Times, July 19, 1983: 2Google Scholar If there is substance to the accusation that radiation oncologists are neither perceived as “members of the club” in academic medicine nor viewed as candidates to be dean because they have walled themselves off from the rest of medicine, do not make rounds, do not admit patients to the hospital, and have become “button pushers in the basement,” then the paucity of radiation oncologists as deans matters greatly.9Kligerman M.M. Gold medal acceptance speech: Comprehensive patient care in radiation therapy practice.Int J Radiat Oncol Biol Phys. 1983; 9: 1091-1092Abstract Full Text PDF PubMed Scopus (4) Google Scholar If a potential talent pool for leading U.S. medical schools and colleges/universities is being overlooked because of prejudice against our specialty and its practitioners or, in the case of leading a university, because of prejudice against physicians, then it also matters. If, on the other hand, only a fool would want to be dean, then the paucity of radiation oncologist deans is a blessing, not a curse, and I am among the accursed. I suppose I did not get the memo since I do not feel cursed in the least. Rather, I have found being dean and now being chancellor, while continuing my clinical work and research as a radiation oncologist, challenging and rewarding. I would recommend both jobs to those radiation oncologists with the temperament and inclination to tackle them. If more take up the challenge, then we can convert the questions which provoked this essay to being of historical interest.