This is the first rule from Joseph V. Simone’s classic and “a must read” manuscript entitled “Understanding Academic Medical Centers: Simone’s Maxims”. Although this at first blush may sound cynical, one simply cannot assume the same respect or appreciation from an enterprise that one would from a friend or family member. Frequently, you will be astonished that even the most wizened senior faculty believes that they somehow merit special dispensation because of their longevity or past productivity or sworn allegiance to an organization. Repeat after me: “What have you done for me, lately?” Simone refers to a colleague who opines that the only true job security is the ability to move to another position, because of professional independence. In these days of rotating Chief Executive Officers and Deans, I am sad to say that institutional loyalty to an individual, especially a chair, cannot be counted upon. Institutional lifespans are long, yours is ephemeral in comparison.

Although I will discuss this later in example number six, the concept of “tickets or chits” should be mentioned here. Jerry Shuck, in his presidential address to the Central Surgical Association, presented the hypothesis that an individual is given a certain and fixed number of tickets when granted a leadership position. The number of tickets granted is a carefully guarded secret that this individual never knows until the last one is spent. The purpose of this digression is that when there is a change in leadership at the Dean or CEO level, the chair’s reserve of tickets may precipitously decrease or disappear.

As Joseph Simone famously said “for academic leaders, the last ten percent of job accomplishment may take as much time as the first ninety percent, and may be not worth the effort.” He goes on to state that the average leadership duration should be 10 ± 3 years. Thomas Starzl reportedly said that surgical chair positions should have durations of 7 ± 2 years. I personally believe that the era of the chairmanship lasting until retirement is a dinosaur, like many of those who did such. New leadership at the Dean, Executive VP, or CEO levels are likely to bring in their own teams irrespective of the successes of the incumbents. Be prepared and try not to take it personally. In addition, it is important to have the insight that you no longer have the passion or institutional support to take your Division or Department to the next level. It is no service to anyone if you are just going through the motions, or as Rumsfeld says, “if you are coasting, you are going downhill.”

In saying this, I must comment that it is not a good thing to be constantly on the search for a better opportunity. There are no well-kept secrets in academic surgery, and if a sitting chair is looking at another position, he or she must be willing to accept the brinksmanship that may result at home. Also, you probably will only receive one retention package. Your second trip to this particular well may result in a firm handshake and best wishes. Simone states that you should consider an academic move only if there is an improvement in anticipated environment and opportunity of 50 % or more. The grass may look greener, but when you get there it most assuredly will not be as green as you thought.

You will also be faced, as a leader, with faculty members who are constantly interviewing for another position. Often, they will tell you this on an initial conversation after you have arrived. Listen carefully, but make no promises or retention offers until you have done your due diligence as to the faculty member’s value and track record of such claims. If the individual was an internal candidate for your position, listen even more carefully and gauge whether he or she will be an ally, or a passive or aggressive impediment to your vision. It is often best to cut the cord and allow them a graceful exit. Beware of faculty who announce that they have another offer, and a better one, as your first introduction to their job hunting. Michael Zinner wisely told me that anyone can have a first interview, or “first date”, but once a second date is scheduled, it is appropriate and respectful to notify the chair.

The late William Longmire once told me that his secret to success as the first chairman at UCLA was to hire great division chiefs and then get out of their way. Of course, he modestly simplified his success. I later learned that this advice originally came from Theodore Roosevelt. Dr. Longmire provided his leaders with resources, support, and promoted them vigorously internally and nationally. He was neither afraid nor intimidated by their excellence. Michael Zinner, inarguably one of the greatest surgical leaders of our time, stated it this way to me, “learn to bask in the reflected glow.” After all, it really does not matter who gets the credit as long as the job gets done well. Rikkers says it this way, “leadership need not be lonely, wise chieftains grant authority and responsibility to those they had delegated assignments”. Do not be afraid of hiring people who are smarter, more accomplished, or even better surgeons than you. Genghis Khan was an icon of political and military genius, but his greatest strength was in the ability to recognize and recruit excellent generals. Rikkers also state that the two most important roles of a leader are mentorship and recruitment. Mentorship leads to retention of those whom you have recruited. Rikkers also states truthfully that a lack of autonomy has been a driver for divisions of surgery to seek departmental status.