Rifat Latifi, Peter Rhee and Rainer W.G. Gruessner (eds.)Technological Advances in Surgery, Trauma and Critical Care10.1007/978-1-4939-2671-8_2

2. The Ever-Changing Departments of Surgery: The New Paradigm—The Roadmap to a Modern Department of Surgery

Rainer W. G. Gruessner¹

(1)

Department of Surgery, University of Arizona Medical Center, Tucson, AZ, USA

Rainer W. G. Gruessner

Email: rgruessner@surgery.arizona.edu

Keywords

Academic surgeryEducationResearchDepartment of surgeryNew technologiesResidencyResources and infrastructureFaculty recruitment and retention

The Different Types of Surgery Departments: The “Old” and “New” Schools

Departments of surgery are not isolated islands; they are and need to be aligned with their respective institution’s mission, vision, and goals. This basic requirement defines the type of a specific department of surgery. As a result, different types of departments of surgery exist:

First, the department of surgery can be part of an academic institution within a medical school or part of a nonacademic healthcare organization with little interest in academic tasks such as research and education. For academic departments, clinical programs are not only revenue-generating units but also essential components for the advancement of research and education; for nonacademic departments, the focus lies primarily on financially solid clinical programs with excellent patient outcome and satisfaction but usually without an authentic interest in research and/or education.
Second, the department of surgery can represent an “old-school” department in which all surgery services and subspecialties are bundled together or a “surgery-core” department which includes general surgery and a few other specialties which are usually not represented in independent departments; this may include cardiothoracic, pediatric, reconstructive, transplant, and vascular surgical services in different combinations. The former allows one to build noncompeting clinical programs and avoids competition for the same patients because of only one departmental leadership structure; the latter almost invites the development of competing clinical programs under multiple departmental leadership arrangements because of the substantial overlap between the different surgical services. One such example is whether the surgical director of a kidney transplant program should be a transplant surgeon or an urologist.

Historically, all surgical services were frequently concentrated under one departmental roof: this included such different specialties as orthopedic surgery, gynecology and obstetrics, ophthalmology, urology, ENT, and neurosurgery. In the 1960s and 1970s, depending on the institutional vision and goals, some of the surgical specialties were organized as independent departments because of strong clinical and academic performance, continued subspecialization, and/or in order to attract some of the brightest faculty and residents. Over the next few decades, this splitting off of the “old-school” department of surgery continued, and, at most institutions, orthopedic surgery, gynecology and obstetrics, ophthalmology, urology, ENT, and neurosurgery have become independent departments. But even “surgery-core” departments have become smaller with cardiothoracic, reconstructive, pediatric, and/or vascular surgical services sometimes splitting off into independent departments. Only more recently, this trend seems to have stopped and some institutions have now begun to reintegrate surgical subspecialties into “old-school” or “surgery-core” departments. As always, financial considerations commonly dictate the setup of institution-specific departmental structures. Due to the explosion of surgical knowledge and techniques over the past decades, the “surgery-core” departments have also substantially grown in their own right and frequently include the following subspecialties: surgical oncology (e.g., breast, colorectal, HPB [hepato-pancreatico-biliary], skin, and soft tissue surgery), endocrine surgery, minimally invasive surgery (MIS, further divided into laparoscopic and robot-assisted services), transplant surgery, trauma, critical care surgery, and, most recently, acute care surgery. Of note, “general surgery” is hardly mentioned as an independent specialty: at many institutions it has been integrated into and absorbed by the different subspecialties.
Third, surgery departments may also be defined by other factors: is the department’s basis only one hospital, is there an additional VA association, or is it embedded in a system-wide, multiple hospital encompassing health system? What is the vision of the institutional leadership—to draw patients primarily from the community or to also attract patients regionally or even nationally? It is important to point out that extremely prosperous clinical programs offered by surgery departments frequently help to define the role and success of the entire institution. One such example is the transplant program that Dr. Thomas Starzl built at the University of Pittsburgh in the 1980s: he almost single-handedly created the largest transplant program of its kind not only in the nation, but in the world, which allowed his institution in years to come to grow into a multibillion health network by purchasing many others hospitals.

Institutional Reporting Structures

The reporting structures are obviously different for academic versus nonacademic institutions.

As surgery departments are solidly embedded into their respective institutions, the chair of an academic department usually reports directly to the dean of the college/school of medicine who appoints the chair and has the power to remove him/her from office as well. However, there are also “dotted” reporting lines to the CEO/president of the hospital or health organization and to the CEO/director of the practice plan. Thus, multiple reporting lines exist and strong alignment among the three entities is absolutely crucial for the success of the institution and the surgery department. If this alignment does not exist—sometimes called the “3-headed monster”—failure and turmoil are almost certain. Although it is rare at academic institutions that the college of medicine, the hospital(s), and the practice plan are united under one leader (usually the vice president of the academic health center), this structure clearly shortens and, in theory, improves the decision-making processes and strategic planning. More often, the hospital and the practice plan are united as one entity, and the college of medicine remains separate; this structure typically results in two separate leadership positions, and close collaboration between the two leaders is the key to success.

In contrast, nonacademic institutions have a different reporting structure. Here, the chair of the nonacademic department usually reports only to the CEO/president of the health organization or to his/her designee. This makes decision-making processes and strategic planning easier. However, nonacademic institutions are not infrequently associated with medical schools and both residents and students may spend rotations away from their academic institutions. In this case, the department chair may interact with the dean of the medical school but is usually not appointed by the dean and does not report directly to him. In case of an independent residency program at a nonacademic institution, a reporting structure to a dean may not exist at all.

At both academic and nonacademic institutions, the surgery chair reports to the institution’s senior administrative leadership. While the surgery chair is in charge of departmental matters, he/she holds only a mid-level management position within the whole organization. Thus, the leader of the surgery department may help to influence key decisions but usually has no final say.

Involvement of the chair or his/her designee in strategic planning, contract negotiations with insurance providers, and other key organizational committees, task forces, etc. is of mutual advantage and benefits the whole organization.

The interaction between the chair and his/her supervisors (dean/hospital CEO) should be of mutual respect and requires the chair’s ability to closely cooperate and to compromise with his/her supervisors. Consensus building and a clear understanding of the issues that the dean and hospital CEO are dealing with (beyond individual departmental matters) are additional attributes to a successful tenure as chair.

Departmental Structure and Organization

The department chair is ultimately responsible for all clinical, academic, financial, and administrative activities within the department. The chair should appoint a strong and loyal deputy chair who will represent the chair in his/her absence. The deputy chair is “primus inter pares” among the vice-chairs. In academic institutions, due to the size of surgery departments, several faculty members may serve administratively as vice-chairs. While there is no definitive number as to how many vice-chairs are required, the following positions are advisable: vice-chair for clinical affairs, vice-chair for academic affairs, vice-chair for financial affairs, vice-chair for education, and vice-chair for research. Other vice-chair positions, such as vice-chair for financial affairs, vice-chair for HR issues, etc. may also be reasonable. The chair, the various vice-chairs, and the division/section chiefs form the departmental “cabinet,” the senior leadership group; it is not unusual that residency director(s), the surgery service chiefs at satellite hospitals, and the administrative director of the department join this group. Sharing responsibilities among the departmental leadership group fosters team work and consensus building.

The vice-chairs are usually in charge of their respective committees which should ideally consist of faculty members from different departmental divisions/sections. The committees should meet on a regular basis and a report should be generated at least twice per year for the chair’s review.

The chair should meet individually and on a regular basis with all faculty members; this is usually mandated by most institutions in order to complete the annual faculty member evaluation. Depending on the size of the department, the chair may have the division/section chiefs meet with their junior faculty, but the chair should be responsible for the evaluations of his/her vice-chairs, division/section chiefs, and senior faculty. Since most academic institutions mandate a departmental mentoring plan for faculty, the evaluations should be based on expectations and benchmarks as defined by the individual mentoring plan. In most departments, division/section chiefs are responsible for mentoring of their junior faculty.

All faculty members should be encouraged to not only be members in their respective societies but also seek leadership positions. Equally important are membership in NIH study sections, national committees, and task forces. These engagements benefit the faculty member, the division/section, and the entire department. Representation of surgical faculty in institutional (college/university) or local community committees is equally significant.

Departmental faculty meetings or retreats should be conducted semiannually. It is important that all faculty members have access to key departmental information including departmental finances—the willingness of the chair to share “sensitive” financial information frequently results in faculty “buy-in” if unpopular measures (most commonly to balance the budget) need to be taken. The more transparent and accountable the chair acts, the greater the support of his faculty. “Cabinet” support for the chair is also essential. The chair has the obligation to be the best departmental steward possible and recognized as such—once the faculty members realize that the chair works diligently and honestly in his/her own and the department’s best interest, support for the chair comes naturally.

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