If you are in academic medicine for any length of time, it’s very likely that at some point someone will recommend that you read Simone’s Maxims. It is also quite likely that this recommendation will come in the context of intoning the first of Simone’s Maxims: “Institutions don’t love you back.” Whether this aphorism ever had its place or not could be debated, but it is abundantly clear, at least to me, that its time has passed. It is time for academic medicine to nurture a more healing kind of institutional humanity and to reject Simone’s First Maxim.
A Bit of Background
The piece typically referred to simply as Simone’s Maxims is an editorial published in the journal Clinical Cancer Research in September 1999, authored by Dr. Joseph V. Simone. The editorial’s title is “Understanding Academic Medical Centers: Simone’s Maxims.” Dr. Simone wrote the editorial in an effort to impart some of the hard-won wisdom that he had accumulated from serving in various leadership positions at academic medical centers. He divides the editorial into five sections – institutions, leadership, recruiting, job changes, and success.
In total, the editorial outlines 22 maxims of varying length and complexity. The shortest are the ones regarding job changes, with most of these running just 2-4 sentences. The longest are in the section on success. I have occasionally heard some of the maxims on job changes offered as advice, particularly “One should consider an academic move only for an improvement in anticipated opportunity and environment of 50% or more” and occasionally paraphrased/summarized as “A move should not be a lateral move.” (I actually like this piece of advice and have both offered and followed it, or tried to.)
In the 25 or so years since its publication, Simone’s Maxims may not be the most heavily cited editorial, logging just 33 citations via Web of Science. However, the HTML full text has been accessed over 24,000 times in just the last 3 years, and the PDF has been downloaded nearly 2,700 times over the last 3 years. For comparison, the other editorial published in that same issue of Clinical Cancer Research has logged just 3 citations, 233 page views, and 13 PDF downloads in that same 3 year period. Simone’s Maxims have clearly had a lasting impact, and the first of those maxims has perhaps been the most frequently invoked. In my opinion, this is not a good thing.
Institutions Don’t Love You Back
The first of Simone’s Maxims, sometimes phrased as “The institution will never love you back,” is arguably the most famous. Indeed, for many, this first maxim is the only one they’ve heard. So that all readers are on the same footing, here is the first maxim in its entirety:
“Institutions Don’t Love You Back.
This first maxim may sound cynical, but the relationship between a trainee, faculty member, or any employee and the institution is impersonal and contractual, whether written or not. Institutional leaders must make decisions that are not personal but usually have positive or negative personal consequences. One cannot expect the same consideration as one may receive in a family. Despite overwhelming evidence to the contrary, it is surprising how often even full professors believe they deserve special consideration because of loyalty, longevity, or past productivity. A wise colleague once told me that job security was the ability to move to another job (because of professional independence). One must keep in mind that institutional relationships are really with persons, who can and sometimes do love you back. My fondest memories of places I’ve been are of coworkers and patients, not “the institution.” If they moved on, my attachment moved with them. For any one of us, good coworkers and solid leaders make what we value in the institution. Recognizing them, what they do for us, and the values they represent are far more important than loyalty to an impersonal institution.”
Simone admits that he is starting off on a rather cynical note. He points out that the relationships between “the institution” and any of the people that comprise that institution are contractual, conditional, and transactional. “It’s nothing personal, it’s just business,” one might say. He then tries to help understand where some people’s confusion comes from by carefully distinguishing the institution from the people that comprise the institution.
He points out that the fondness and loyalty many of us feel in regards to an institution are actually more properly connected to the people at that institution. The point is driven home with a bit of a thought experiment: “One must keep in mind that institutional relationships are really with persons, who can and sometimes do love you back…. If they moved on, my attachment moved with them.” This invites the reader to consider the alternative possibility of an attachment to someone dissolving immediately when they leave the institution. This seems absurd. Of course we maintain relationships with people when they leave the institution! To do otherwise would seem borderline sociopathic and would run counter to how most of us understand human relationships to work. So, the conclusion seems to be that the institution is fundamentally not the same thing as the people that make it up, a conclusion that is driven home by the sentence that follows: “For any one of us, good coworkers and solid leaders make what we value in the institution.”
This dichotomy of the institution vs. the people who comprise the institution seems to be at the heart of Simone’s First Maxim. “Institutions won’t love you, but the people there might. Try not to confuse or conflate the two.” Why, then, does this still rankle so?
Even If Institutions Can’t Love You Back, People Can
There’s a statement early on in Simone’s First Maxim that is very interesting in light of what follows. He says: “Institutional leaders must make decisions that are not personal but usually have positive or negative personal consequences.” In other words, institutional leaders must make decisions that are in the best interests of the institution and not necessarily in the best personal interests of the people who comprise the institution. On the surface, this is somewhat understandable, made more so with the establishment of the dichotomy between the institution and the people who make it up. However, there are a couple of problems that arise.
First, let’s suppose that institutional leaders made a series of decisions that were in the best interests of the institution but that had increasingly negative personal consequences for an increasingly large proportion of the people who comprise the institution. Does the institution itself suffer? If so, at what point or threshold? At what point does the failure of the people to thrive become the failure of the institution itself to thrive? If the institution and its people are truly separate and separable, the answer could conceivably be that no such point exists. But that conclusion fairly quickly runs counter to our basic intuitions. If there were no point at which personal harm equated to institutional harm, institutions should cut all wages by 50% and increase all fees by 50% at least. Great for the institution, not so much for the people who comprise it. It seems equally absurd to say, “This decision hurts each and every one of you profoundly but is good for the institution” as it does to imagine ending a connection to a person because they’ve left the institution.
The second and perhaps bigger problem, though, has to do with what seems to be a confusing notion of “institutional leaders.” Simply put, these are people. Even if institutions don’t love you back, people can. But from Simone’s description of institutional leaders as having to “make decisions that are not personal but usually have positive or negative personal consequences” it can be hard to reconcile institutional leaders as people who are behaving in decidedly non-people-like ways and prioritizing the institution. If that personally benefits you, great! If not, well, nothing personal, it’s just business? That would seem to require that great institutional leaders possess a distressing degree of psychopathy/sociopathy, something that is almost certainly not the case for most institutional leaders.
This confusing notion of institutional leaders, for me, is the crux of the problem with Simone’s First Maxim. The place where the interests of the institution and the interests of the people that comprise it come together and either mesh or clash is the institutional leadership. If the institution is a trolley, institutional leaders collectively are the operator, often faced with very small and sometimes quite large versions of the Trolley Problem, versions in which one of the options is to run the trolley directly into a brick wall. Regardless of the variation or the outcome, the Trolley Problem at no point tempts us to say, “Well, the trolley doesn’t really care.” Such a response would seem to willfully miss the entire point of the Trolley Problem and would be infuriating in its obtuseness, especially to the people in the trolley or on the trolley tracks.
Institutional Leaders Aren’t Always Able to Choose Love
Academic medical centers, the subject of Simone’s Maxims, attract the best and brightest minds in the world, and very deliberately so. It is then somewhat surprising that these collections of literally the smartest people in the world would be advised to accept such a logically flawed premise of institutional leadership as just being the way things are and must be. It is a notion that definitely could help to protect the mental and emotional well being of institutional leaders themselves, as they are in the very unenviable position of having to be at once people who do love other people back and representatives of the institution, which does not love people back. As an institutional leader himself, one can imagine how this might hold some appeal for Simone.
It may not be possible to make the job of an institutional leader easier or more comfortable, and it’s not entirely clear that it should be easy or comfortable. Indeed, great leaders may be those people who do feel the agony and the weight of decisions and who are able to make those decisions anyway without losing their human connection to the people that comprise their institutions. If that sounds like a position that few would want and to which few would be suited, that is likely because that’s true.
Reframing Simone’s First Maxim as something like “Institutional leaders aren’t always able to choose love” has a couple of interesting follow-on effects. It helps to resolve the somewhat bizarre (and potentially false) dichotomy of institution vs. the people who make up the institution and hopefully helps resolve some intrinsic cognitive dissonance related to that dichotomy. It also restores personal agency to institutional leadership, a blessing that brings with it a much greater requirement for transparency, honesty, and accountability. “The institution” doesn’t do anything, any more than the trolley itself in the Trolley Problem does anything. Institutional leadership makes decisions. The Trolley Problem has moral weight in part because we feel the agony of the decision-maker. We can empathize and at least to some degree understand the decision-maker’s plight. But, in the real world, we would want to know how the trolley operator arrived at their decisions. Understanding the hows and whys would matter to us very much, almost as much as the decisions themselves. When dealing with some of the smartest people in the world, institutional leaders might reasonably expect that making clear the hows, the whys, and the struggles of decision-making would be met with some empathy and understanding.
Trusting smart people to understand that institutional leaders aren’t always able to choose love seems to me a much better bet than asking those same smart people to simply accept that the institution won’t love them back. It’s even possible that such understanding might inspire them to think of solutions and decisions that actually allow institutional leaders to choose love more often. That is, after all, the kind of thing that academic medical centers are built to do, right?