Upstairs Downstairs: How many clinical shifts should a department chair work?


Dear Director,
I work in a community ED, and we just got a new chair. He goes to a lot of meetings, but he’s barely working any clinical shifts. And when he does, it’s only the easy day shift and never a night or weekend. How much do you think an administrator needs to work in the trenches to pull his or her weight?

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While every ED is different, the most important job of the chairman is relatively similar—maintain the contract. This might seem superficial at first, but this single objective addresses improvements in the ED’s quality and performance on all levels. The chairman does most of this work behind the scenes, not in the exam room.


What’s Normal?
The chairman’s contract – which is influenced by ED volume and the complexity of the hospital – will strongly dictate what percent of their time is spent clinically versus administratively. This may range from 20% clinical (about four shifts a month) to 80% clinical. I had one friend who received no protected administrative time as a chairman, but that’s an extreme case… and usually a setup for failure. While academic chairs and those supervising several EDs tend to work significantly less, most chairmen are in the 6-10 shift a month range (50-100 clinical hours).

Starting Strong
In general, I’m a big believer that new chairmen need to work shifts, and that some of these shifts need to be nights and weekends. They need to build a team and develop credibility with their staff, and this happens best on the floor, not in a back office.

In addition, new chairmen should use these shifts to show everyone that they can still walk the walk. In my second week as a new chairman, one of our nurses had an anaphylactic reaction in the break room at midnight on a Saturday night. As she was wheeled into our critical care room, it was up to me – the solo night doc – to intubate her as her face swelled, her throat closed and her O2 stats dropped. I did a quick airway assessment—no neck, morbidly obese and minutes from dying.


This is a stressful situation in the best of circumstances, not to mention the pressure of caring for a staff member and knowing that everyone is wondering if I can do the clinical job. I did get the airway, the nurse did receive treatment, get admitted to the ICU and make it back to work. And we all learned to keep the crab soup out of the lounge when she was working. After I showed that I could still do clinical tasks, this gave me instant street cred with the staff and was talked about for weeks. It showed everyone that I had the clinical skills and that I wasn’t just there to manage operations.

Contrast that to the time I took a job knowing that the ED had several recent STEMI misses and the top administrative priority from the CEO was to eliminate these “misses.” I was in my first week and still learning my way to the cafeteria when I read a triage EKG on a 30 year old with vague chest pain as J-point elevation. Fortunately, the doc seeing the patient minutes after my interpretation recognized the STEMI and politely asked me for a second opinion. He activated the cath team and the door-to-balloon goal was met. Had the miss occurred and fallen on me, my credibility with the CEO would be forever blown and likely my tenure as chairman would have been short lived. This never hit the CEO’s radar, and the doc in my new group cut me some slack and never mentioned it again.

Work the Tough Shifts
Working the off-hour shifts lets your team know that you’re willing to pull your weight. This builds group camaraderie. It has the additional benefit of looking good to new recruits since if they see the chairman on the schedule for nights, weekends, and holidays, they will believe that things are fair. We all know that hospital life is different during nights and weekends, so working these shifts will keep you aware of the unique frustrations they present, whether that’s an EMR downtime, the inability to get a consult or just the need to read your own plain films. That will, in turn, build trust from your staff that their concerns are understood.

I’ve taken over two EDs as a chairman being brought in from the outside and in both instances I found that it was easier to get my finger on the pulse of the department by literally working every shift that was on the schedule. It took many extra shifts above my contracted time and it took a few months, but it was the best way to understand certain flow and coverage issues — basically what the staff were complaining about.


While it’s wise for chairmen to work the tough shifts to understand their departments and staff, this must be balanced against the realities of the position. In the end, being in the office during regular business hours does help a chairman best accomplish their ultimate goal of improving the ED. And when chairmen work the night shift, they basically lose two administrative days on either end. Working weekends puts you in the position of potentially working 12 days in a row, since the expectation may be that the chairman is in the hospital every weekday. It’s rare for an ER doc to work this much straight through, but it’s what we sign up for as chairman.

I’ll be honest. The first six to twelve months as a new chairman, particularly if you’re in a new site, sucks. You work a ton. You’re pulled in numerous directions while trying to figure out what meetings and people matter and what you can delegate. You’re also figuring out the clinical piece and building your team, which often requires recruitment (another time and schedule intensive process).

The best way to succeed is by maintaining as much control over your schedule as possible. For most people, this doesn’t mean completely avoiding nights and weekends but rather hand picking your clinical shifts (including a fair mix of all shifts) so they complement your administrative schedule. I have days where I have meetings from 7a-11am; working an overnight shift that day would be really hard but those meetings feed really well into our 11a-8p shift. At this point in my career, I really don’t want to be in the hospital more than 12 hours in any day. About once a month I have a 15 hour day but I can’t do many of them or I’m too useless the next day and that much more burned out.

The End Game
Over time, and with enough clinical work behind them, there are many chairmen who significantly reduce or eliminate nights and weekends from their schedule. Most of these have the support of their group because they’re doing an excellent job. These chairmen work long hours and have a presence in the ED, which includes evening shifts to interact with night staff and evening and weekend rounding. They also are visible around the hospital, and have the support of the CEO. If the department is successful, the chairman has a very strong administrative presence. And, if he or she has built up credibility in the clinical arena, staff will understand the decrease in night and weekend shifts over time.

But most chairmen should do their “share” of weekends and nights. This doesn’t mean it needs to be as many as the full time clinicians but should be somewhat pro- portional to their total clinical time. The administrative priorities will usually win out over the off hours shifts. But to help optimize clinical availability chairman, no one in the group should complain when the chairman hand selects their shifts.

So, recognizing that you’re looking for specific advice for your particular (and delicate) situation, I would advise that you start with learning more about your new chairman’s priorities. Ultimately, you need to decide for yourself if he’s showing improvements that positively impact you in the ED. These don’t happen when he works clinically. As a new chairman, I often found it effective to let each person in my group know what my job priorities were so I could set their expectations around what my clinical and non-clinical work schedule would be. If you still feel the need to approach them, tread carefully. Telling a new boss he needs to work more nights and weekends may not make the best first impression. Of course, you could casually ask them if they had plans to work nights and weekends to experience the issues that occur then or maybe leave this column on his desk…



EXECUTIVE EDITOR Dr. Silverman is Chair of Emergency Medicine at VHC Health. He also taught a leadership development course for over a decade. Dr. Silverman’s practical wisdom is available in an easy-to-use reference guide, available on Amazon. Follow on Twitter @drmikesilverman


  1. We need to pull our head out of the sand and realize a chairman needs to be doing less clinical and more administrating. The ‘building the credibility’ argument I think is baseless. Build credibility by putting your effort and resources into making the ER a more efficient system, with processes that improve the lives of the physician and the patient. Do not look to your chairman for their clinical expertise and ability to maintain horrible work-life balance by working as many nights and weekends as they can muster. Look to your chairman as a CEO who focuses on the big picture of operations, leadership, marketing, finance, human resources.

  2. I agree. for far too long ED chairmen have been called on to do double duty. In an age where most CNOs and even nurse managers have MBAs, the ED physician chairman needs to be competetive with his time and skills. You cannot “part time” administration under these conditions. If we want to be viewed as administrators we need to be there when they are there (and we need to be awake and alert). We need to stop the nonsense of “credibility”. Its not like we just got out of residency. Most chairmen have years of experience and have “proven” themselves. I think contract companies and hospitals need to decide whether or not they want administrators who can make a difference or a clinician who is a part time administrator .

  3. Is it fair to say that the chairman’s job is to keep the department in good standing with the administration (and community), maintain a cordial work environment amongst clinical staff, lead the team for success, pull your own weight and all of this without killing your self (or others)? – Darn, that’s a lot!

  4. Recently retired from full-time hospital leadership work, including a stint as ED Chair, I offer a caution as supplement to Dr. Silverman’s advice regarding clinical work for emergency medicine department chairs.

    No doubt, clinical work is essential and Dr. Silverman describes a sensible approach to gaining clinical credibility–the cornerstone of leadership for any clinical service leader. However, I do not believe working shifts gives a new department chair a cleareyed view of how the department operates. Yes, work the shifts including the difficult ones, but recognize as chair, you’re always “handled” differently by the rest of the staff.

    In a usually unconscious effort to win or maintain favor with the chair, clinical and support staff go above and beyond. Sometimes to deflect attention to other parts of the team, you’ll experience things that are “setups” to focus your attention there. Rarely, someone out to get you–the chair–will endeavor to sabotage you more directly. Face it, you are a different character, not just another emergency physician.

    Manage this challenge by getting to know your staff. Yes, staff meetings are important. Private one-on-one breakfasts, lunches and early evening dinners are essential to learning about the personality of each physician staff member and nursing leader and over time create the opportunity to draw out each clinician’s views and experiences. Trust them and show them that you do. Don’t “out them” in a meeting as a source of information, but do make a necessary change and communicate it clearly to the group as a consequence of your learning directly from one or more of them.

    Practice this behavior continuously throughout your term as chair and your schedule alterations and cutting back on nights will elicit much less criticism.

    In time, you’ll know a great deal about how the ED really works on different shifts and at different seasons and your staff will know that you can be trusted to do the right thing with the experiences, observations and opinions each entrusts to you, their trusted ED Chairman.

  5. stephen G Holtzclaw on

    I am a former Emergency department chairman and currently have operational oversight of more than 100 emergency departments across multiple states. In addition, I continue to work clinical shifts in the Emergency department every month.This allows me to stay abreast of the complexities of our specialty as well as helping me to maintain credibility among my peers. I agree with Dr. Silverman’s approach to balancing clinical work with administrative responsibilities. In fact most of the directors that work with me start out dividing their time in a 50/50 split. Later the amount of clinical time is adjusted based on the ever growing administrative responsibilities.

  6. Thank you for the comments and for sharing your opinions. The job of the medical director has increased in complexity and time demand over the last 10-15 years. I am sure it will continue to evolve with more administrative responsibilities as we keep working to improve quality, patient safety, and provider efficiency. Because community EDs and hospitals differ so dramatically (volume, size, complexity of meetings and administrative responsibilities), the clinical job responsibilities of a chairman will vary as well. Smaller hospitals with lower volume EDs may only require 10 administrative hours a week while a tertiary care hospital with ED volumes >100K will require significantly more. Although our ultimate deliverable is to have a well running ED where patient’s receive high quality care and the physicians and staff have the tools to do their job, the doc on the front lines still expects to see their chairman work clinically. We are not CEO’s (the hospital has one of those), we are managers and as such need our staff to respect our skills when we call them in to discuss patient sat, core measures, productivity, or a bad outcome. While I’ve often joked with my team about the “magical chairman white cloud, ” (ranging from lower patient volume, improved nursing attentiveness, and easy interactions with the hospitalists) which makes my shifts smoother than for others, the drug seekers, the critically ill or the ticked off specialist don’t care that I’m the chairman and treat me like any other doc in the group. Dr. Davidson gave great advice on having regular 1:1 meetings with the docs, preferably outside of the hospital—this is something I do as well and have encouraged new chairman that I mentor to do also. As leaders, our job is to build a bigger and better program. There are many ways to get that done. Before we leave the clinical areas completely, ask your docs, nursing leaders, and the C-Suite if they see benefit in you working clinically. Their answers might surprise you. And at least for now, in a community setting, it’s very unusual to find a medical director in any specialty who doesn’t work clinically.

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