LAUSR

TO THE EDITOR: I read Detsky and Gropper's commentary (1) with great interest and would like to present a counterargument. There is, perhaps, consensus that—within the department—researchers, section chiefs, chairs, and others in administrative roles will participate in clinical practice. I also stipulate that some participation in professional societies, national committees, and other organizations is of recognized value but expected to be incorporated into the rubric of “other duties as assigned,” with limited allocation of additional resources or time. Certain higher positions within those organizations might come with the expectation of limited clinical practice during the term of office but full clinical participation thereafter. However, once elevated to a permanent leadership position above the level of the department—chief medical officer, chief medical informatics officer, chief executive officer, or similar—I believe it is wrong, for both the patient and the institution, to expect direct patient care. As Detsky and Gropper state, “Everyone who leaves clinical care, even for a short time, quickly loses the emotional intensity and detailed clinical knowledge that allow full understanding” (1). To perform a leadership position at a superlative level, one must focus the emotional (and, I would argue, intellectual) intensity on that position. To believe that a clinical or leadership position can be done with a fraction of that focus does a disservice to each. Further, consider lifetime learning. How do we expect someone to stay current in their clinical specialty while at the same time learning and then advancing their knowledge of the administrative environment, regulations, strategies, technologies, and the like for this new role? Where is time for reflection, insight, and imagination to be allocated? To whom would you refer your mother: a 100% clinician at the top of his or her game or a 25% clinician–administrator whose focus is elsewhere? Leadership roles are, perhaps by their very nature, interruptive and disruptive. The headache-of-the-day waits for no one. “Can you cover for me while I run to this urgent meeting?” is often heard, as are intruding telephone calls in clinic. Where is the intensity focused in that situation? Lastly, it is not a matter of credibility but of time. If you are considered for a leadership position, then you probably bear, admirably, the scars characteristic of the trenches in your specialty. Street cred is the summary of your past performances and stands on its own. In a leadership position, is it not better to spend what would have been clinical time instead listening to colleagues, staff, and employees in other areas of the institution, absorbing their input into your personal experience and knowledge? Colleagues will appreciate your empathy, understanding, and commitment to resolve more than the knowledge that you have experienced the same issue firsthand. In the end, the decision is how best to serve the patients of an institution. Once you decide that is best done on an administrative path, do you not then owe it to those patients to throw all of your intensity at it?