Chair's Column: The Departmental Division Director – Straw Dog or Change Agent?

The Departmental Division Director – Straw Dog or Change Agent?

The Department of Medicine currently comprises 775 full-time faculty members across 20 medical specialty divisions (Figure 1), overseeing more than 1,000 trainees, residents, and fellows across our affiliated hospitals. Each division is led by a Department Division Director (DDD).

Figure 1: Number of full time faculty members (2018)

The hospital Physicians-in-Chief (PICs) and I rely heavily on the DDDs to help us build and maintain a thriving academic enterprise. The DDD is essential in supporting community, purpose, leadership, mentorship and communication within our academic community.  But, despite what I think, there is a perception among some of our faculty that the DDD role is ‘without power’ – that the DDD is a ‘straw dog’. In this Chair’s Column, I’d like to respond.

In my early days as Chair, I wasn’t entirely clear about the DDD role and observed substantial variability across divisions with respect to their activities and engagement. They were under-resourced (for most, the medical secretary played dual roles as the divisional admin). Prior residency training reviews had also identified insufficient support for residency training program directors as a concern. We needed to take action.
Revisions to the DDD Roles and Responsibilities

To better understand how our divisions were functioning, we conducted 360-degree divisional leadership reviews and external divisional reviews. The feedback has been overwhelmingly positive. Three common themes emerged that have helped us to shape the DDD role:

• First, respondents underscored the value of a clearly articulated vision and goals for the division and the role of the DDD in setting this direction. Not only did they express the desire to have clarity regarding where they are going, but also why, how they will get there and what it will look like when they arrive.
• Second, the importance of strong communication by the DDD with divisional members, key stakeholders and trainees was emphasized. While many DDDs were praised for their desire for consensus-based decision making, it was noted that some had difficulty moving forward when consensus could not be reached.  Conflict resolution skills were also seen as desirable among DDDs.
• Finally, there was an over-arching theme of putting what’s best for the whole division first, ahead of personal or site-based priorities. Historically, DDDs were often also hospital Division Heads, which has potential to create conflict-of-interest. Particularly for the smaller hospital sites, there was a clear desire for the DDD to value all equally.

We used this feedback to revise and expand the DDD job description and establish the key attributes of a successful DDD. There was consensus a five-year term as DDD, renewable upon successful review, was appropriate. With such a spectacular faculty to pull from, we needed to give others opportunities to lead.

Current Roles and Responsibilities of the DDD

The DDD role in our department is complementary to that of the PIC at our affiliated hospitals: they share a mandate to build and maintain a thriving, financially sound, unified and equitable academic enterprise. The PICs and DDDs work closely with their hospital division heads and the DoM leadership team to achieve this goal, as shown in the figure below,

Recruitment
The DDD plays an important role in faculty recruitment. The DDD is important in the assessment of physician needs within the subspecialty, and therefore in identifying recruitment needs. In concert with the relevant PIC(s), the DDD may instigate recruitment and participates in all searches as a representative of the University department. For most if not all divisions, recruitment is a standing item at divisional executive committee meetings.

The DDD’s knowledge of trainees, both current and prior, and the divisional landscape is invaluable to identifying potential candidates and ensuring that all faculty recruits are positioned to succeed in their chosen academic career, including ensuring the right hospital fit and availability of resources including mentorship. To this end, both PIC and DDD must review and approve the academic and mentorship plans of new recruits.

Mentorship of Faculty across the Academic Lifespan

The DDD serves as a vital informal mentor for both trainees and faculty members; they are an advocate for the general wellbeing of their faculty members. The DDD is also ‘neutral’; he or she can provide a safe space to discuss sensitive issues, such as professionalism within or across sites. At Continuing Faculty Appointment Review (CFAR) and senior promotion, the DDD is critical to faculty members’ success. For example, at promotion, the DDD is central to articulating the impact of the faculty member’s scholarly contributions to their field.
Education:

The DDD is responsible for the accreditation of their subspecialty residency training program, the integrity of its clinical and research fellowship programs, and the overall experience and satisfaction of its learners, including undergraduate MD and core medicine trainees. They do this by providing strong support to their Residency Program Director (RPD), Residency Program Committee and other divisional education leads. They work closely with the RPD in resident selection, program delivery, career mentoring, evaluation of trainees, evaluation of faculty teachers and fostering a culture of support and accountability among all.

Communication:

As I have said before, communication across this multi-hospital department is far from simple. Over the last few of years we have invested resources to improve our communications (website, newsletter, weekly digests, etc.). Our DDDs and divisional staff and faculty members work closely with our DoM lead for communications, Brianne Tulk, to ensure effective community-wide communication.

Funding and Advancement:

The DDDs work closely with our Business Director, Clare Mitchell, and DoM Advancement Officer, Chris Adamson, to manage divisional funds, raise new funds and steward existing divisional donors. Careful attention to and engagement of existing donors is time well spent.  In this era of fiscal restraint, fundraising is essential to support academic activities such as rounds, research seed grants, awards, research day, CME events, journal club, etc.

Supporting our Divisions and their Leaders

This is a tall order! We had to ensure the divisions were sufficiently resourced – or at least as best we could – to deliver on this mandate.

To this end, in 2014, we conducted a survey of the divisions, which asked them to identify and rank order their priorities for divisional funding.

There was amazing consensus that the following support was critical to their success:

• Administrative support for the DDD and RPD;
• Appropriate PD stipend;
• Opportunity to hold annual divisional retreats; and,
• Access to discretionary divisional funds to enable support of city-wide initiatives, trainee attendance and presentation at conferences, faculty and trainee awards, and other activities. 

We developed and implemented a process by which allocation of divisional resources would be done, which reflected divisional size (full time faculty and residency training program). My predecessor, Wendy Levinson, had already begun to establish divisional chairs – endowed monies to be used by the DDD to support divisional activities – and this has continued. We also sought to align existing endowments to the divisions as appropriate. Today, we have divisional endowed chairs for nine of our divisions. 

There was also agreement that additional UofT DoM support was needed to support the divisions in communications (website, newsletters, etc.), advancement (fundraising), research, education, QI, mentorship/faculty development and finances. Under the superb leadership of Clare Mitchell, recruitment of additional staff to serve these roles has taken place.

While more resources are always better, when asked, most of the DDDs said that they had sufficient resources to carry out their duties (they would like additional funds to partner with the hospitals in recruitment activities, as would I!).

Leadership Development and Mentorship

As noted, the DDD role is a challenging one, which relies strongly on communication, collaboration and motivational leadership. Thus, careful selection of our DDDs has been a focus, along with formal leadership training or coaching as appropriate.

All DDDs are members of the DoM Executive Committee and, as such, play an important role in shaping the direction and policies of the department. You won’t be surprised that this is a feisty group without a shortage of opinions on almost everything! As such, participation in this committee provides a valuable leadership experience for our DDDs. In addition, our DDDs are provided with formal leadership training or coaching, as appropriate. We have also created a quarterly meeting of the DDDs in order to hone in on issues that are of specific importance to this group. There is enthusiasm among the DDDs to further enhance their sharing of best practices, which is fantastic!
While this is great, perhaps the biggest perk of the DDD role is the daily interactions with their incredible trainees and faculty and the opportunity to grow a collaborative division that truly is greater than the sum of its hospital parts. There are innumerable examples of how our DDDs have done just that, including creation of city-wide triage programs for clinical diagnoses, city-wide research and QI networks working on common projects to enhance knowledge and clinical care, continuing education initiatives that not only educate but showcase our first class faculty and raise funds, and many others.

Let me close by coming back to the question I posed above: is the DDD a straw dog or change agent? In their own words, this is what three DDDs had to say:

“A division is a big boat and I only have a small rudder, so while it can be tough to make sudden direction changes I can steer the big curves.”

“The role is what you make of it”

“You can achieve your goals if you go about it the right way…with respect, enthusiasm, honesty, collaboration and a positive outlook”