How Chairs Decide Whose Name Goes on Big Opportunities and Why

A chair once slid a conference invitation across my desk and said, “I could send the ‘best person’… or I could send the person who’ll still be here in 10 years.” The “best person” on paper didn’t get the slot. The person who had been showing up to thankless committee meetings for three years did.

If you think big opportunities are handed out based purely on merit, you’re still reading the brochure version of academic medicine. Let me walk you into the back room and show you how it actually works.

---

What Counts as a “Big Opportunity” (in the Chair’s Mind)

You and your classmates don’t always label the same things as “big” that a chair does. Chairs are thinking in terms of institutional visibility, power, and long‑term strategic positioning.

We’re talking about:

• Being 1st or 2nd author on the “flagship” paper from a major project
• Getting nominated for national society committees or guideline panels
• Being put forward to give a high‑profile invited talk or grand rounds
• Leading a multi‑site trial or core in a big grant
• Being named “course director,” “service chief,” or “quality lead” for a visible initiative

These are the things that show up on promotion packets, dean’s reports, and external reputation metrics. They’re also finite. A chair might have three national slots to give in a year and twenty people who’d love one.

So the real question isn’t “who deserves it?” The real question in the chair’s head is:

“If I bet this scarce, high‑visibility chip on you, will it pay off for me, the department, and the institution?”

That’s the frame everything else hangs on.

---

The Real Criteria: What Chairs Actually Look At

Forget the official language in the faculty handbook. When a chair is sitting alone with the list of names, here’s what truly drives the decision.

1. Reliability Over Raw Talent

I watched a chair at a major academic center cross off a star resident’s name for a national presentation because, in his words, “I’m not gambling that she won’t flake again.”

She’d ghosted on a minor abstract deadline six months prior. Brilliant resident. Killer data. But she dropped a poster three days before the conference because she “wasn’t happy with the figures.”

What did the chair remember? Not her brilliance. Her risk.

Chairs value:

• People who meet deadlines without drama
• People who don’t need hand‑holding for every email or slide
• People who say yes sparingly, but then actually deliver

You want a harsh truth? A B+ person who is boringly reliable will be chosen over the A+ diva almost every time for high‑stakes stuff.

2. Risk to the Chair’s Reputation

Nobody says this out loud to trainees, but: every person a chair sends out into the world is a reflection of the chair.

If you blow a talk, come off as arrogant to a national committee, or ghost on a multi‑site call, the feedback doesn’t just come back to you. It comes back to your chair in phrases like:

“Thanks for sending Dr. X, but next time maybe someone else?”

So chairs are constantly running a quiet risk calculation:

“Are you going to embarrass me publicly, politically, or professionally?”

That risk has layers:

• Clinical risk: Are you going to leave service uncovered, trigger complaints, or miss patient care?
• Political risk: Are you going to say something tone‑deaf to the dean, the CEO, or the national society leadership?
• Professional risk: Are you going to show up late, under‑prepared, or obviously phoning it in?

You might be the smartest person in the room. But if your chair has ever had to apologize for you—lateness, rude email, poor communication—your name drops several spots for prestige opportunities.

3. “Return on Investment” for the Department

Chairs are not Santa Claus. They are investors. When they decide whose name goes on a big grant, big talk, or big committee, they’re thinking:

“If I give you this, what comes back to me and this department?”

The ROI they’re looking for:

• Future grants with the department as home base
• National committee roles that increase the department’s clout
• Reputation enhancements that help with rankings, recruitment, and philanthropy
• A future division chief, program director, or associate chair who stays

That’s why borderline good people with obvious long‑term loyalty often beat out stellar folks who look like flight risks.

If you’re constantly talking about going to industry, switching institutions, or jumping specialties, don’t be surprised when your chair doesn’t put you as the face of a 5‑year national initiative. They assume you’ll be gone before the payoff.

4. Political Debts and Alliances

This is the part nobody likes to talk about when they’re on the outside. Chairs owe favors. They trade them.

• The dean asked them to “support this rising star” from another department
• A powerful senior faculty member wants their protégé launched
• The hospital CEO wants more visibility for a particular service line

So sometimes the internal ranking is:

1. Person the chair must pick (political pressure or explicit ask)
2. Person the chair wants to pick
3. Person who technically “deserves” it based on merit alone

I’ve watched chairs say, in closed meetings: “Yes, Sarah’s probably more deserving. But I owe John one, and if I don’t move his junior up on something this year, I’m going to pay for it on the budget votes.”

It’s ugly, but it’s real.

5. Who Is “Safe” Socially and Culturally

Look at who gets sent to external things. You’ll see a pattern.

Chairs favor people who can:

• Talk to anyone in the room, from a med student to a CEO
• Handle conflict or tough questions without getting defensive
• Avoid needless drama, gossip, or personal oversharing in professional spaces

If your chair has ever thought “I don’t know what version of them I’ll get today,” your name is not at the top of the “send them to represent us” list.

Basic emotional regulation and social awareness become high‑value traits when you’re being sent into rooms full of egos.

---

The Shadow File: The Stuff That Never Goes in Writing

Here’s the part that stings for a lot of smart, hardworking people: your chair is keeping a silent, informal ledger in their head. It’s not official. But it’s real.

It includes things like:

• Who shows up to low‑glamour tasks (M&M prep, recruitment dinners, curriculum revision)
• Who disappeared the minute residency/fellowship graduation was secure
• Who only emails when they want something vs. sharing wins, updates, and team credit
• Who has made the chair’s life easier vs. harder

Let me give you two composites I’ve seen again and again.

Dr. A

• Brilliant, high‑volume publisher
• Always a bit late with drafts
• Complains often about “wasting time” on committees
• Seen by staff as “demanding” and occasionally dismissive

Dr. B

• Solid but not spectacular CV
• Volunteers early for at least one unpleasant, necessary departmental task each year
• Staff like working with them; they say thank you
• Keeps the chair in the loop with quick, concise updates

Who do you think gets the chair’s quiet advocacy for “emerging leader award,” “national young investigator spotlight,” or “important society committee”?

It’s B. Over and over. Chairs know they can build B. A might succeed brilliantly, but is just as likely to blow up a relationship they need.

---

How Names Actually Get Picked: The Informal Process

You imagine a careful, criteria‑driven review. What actually happens is much messier and faster.

How a Chair Picks Names for Big Opportunities

Step	Description
Step 1	Opportunity Appears
Step 2	What does the institution want
Step 3	Chair makes shortlist
Step 4	Add protege of key ally
Step 5	Proceed with internal picks
Step 6	Risk and ROI gut check
Step 7	Offer opportunity
Step 8	Pick safer backup
Step 9	Is there a political debt
Step 10	Is this person safe to send

Here’s roughly how it goes behind closed doors:

A major society emails: “Nominate one person from your department for this national committee / early career award / task force.”

The chair does not open a spreadsheet and rate everyone. They:

1. Think of 3–5 names that immediately come to mind.
2. Mentally cross off anyone who is high‑risk, high‑maintenance, or politically awkward.
3. Filter the remainder through: “Who have I invested in? Who’s been loyal? Who can I trust not to embarrass us?”
4. Then, if there’s time, maybe they send an email to division chiefs asking: “Anyone I should be thinking about for X?”

If your name isn’t coming to mind at step one or two, you’re already behind. That’s where “networking in medicine” actually lives—with your name living rent‑free in the right people’s heads.

---

Visibility vs. Proximity: Why Some People Always Seem to Get Picked

You’ve probably noticed a pattern. Certain residents, fellows, or junior attendings somehow end up on:

• The cool research project
• The teaching award nomination
• The national committee the chair sits on

It’s not random. And it’s not always that they’re “favorites” in the childish sense. It’s proximity and repeated exposure.

Chairs are busy. They don’t sit around studying everyone’s CV. They remember:

• Who has been in their office more than once—and not always asking for something
• Who presents well at conferences, M&M, grand rounds
• Who other powerful people mention positively by name

Think of it like this: there’s an internal “top of mind” list inside every chair’s brain. That list is built from:

What Drives 'Top of Mind' Status with Chairs

Category	Value
Direct interactions	40
Word-of-mouth from trusted faculty	30
Public performance (talks, conferences)	20
Paper CV review	10

Notice what’s smallest: “Paper CV review.” Chairs don’t sit with PubMed open trying to find the perfect person. They default to who they already know and have seen.

That’s why the resident who spends a year quietly killing themselves on a chart‑review project, never presents, never speaks up, never meets the chair outside a perfunctory handshake… loses to the resident who gave two excellent talks, served on a single important committee, and chatted with the chair after grand rounds three times.

Not because life is fair. Because chairs are human and overloaded.

---

The “Pipeline Bet”: Who Chairs See as Future Leaders

Here’s another level most trainees don’t realize exists. Chairs are constantly scanning for who they can groom as:

• Future program director
• Future division chief
• Future associate chair

Those people will get a wildly disproportionate share of “big opportunity oxygen.”

They’ll be:

• Given first dips on high‑yield committees
• Pushed onto society tracks (“You should run for council in the next few years”)
• Put on the big grants, even when others did more of the boring groundwork

Is it fair to the worker bees? No. But from the chair’s vantage point, this is pipeline building. They’re investing in people they believe will eventually help run the place.

So if you look around and wonder why one or two people in your cohort are suddenly everywhere, ask yourself:

“Does the chair see them as future leadership? What boxes did they check to send that signal?”

Usually it’s a mix of: decent scholarship, strong interpersonal skills, low drama, institutional loyalty, and a hint of political savvy.

---

How to Get Your Name Moved Up the List (Without Being Obnoxious)

You’re not going to change how the game is played. You can, however, change how visible you are to the people holding the cards.

Here’s how I’ve seen residents, fellows, and junior faculty quietly move themselves from “anonymous” to “go‑to” in a year or two.

1. Build a Track Record of Boring Reliability

Do not underestimate how powerful it is for a chair to hear the same refrain from multiple people: “They always get things done. On time. No fuss.”

That means:

• If you say yes, you treat the commitment like a contract
• You send drafts early, not minutes before deadlines
• You do not make your failure someone else’s emergency

Once a chair mentally files you as “safe pair of hands,” your risk score drops. That’s the doorway to bigger stuff.

2. Take at Least One “Unsexy but Visible” Role

I’m talking about roles that chairs actually notice:

• Residency or fellowship recruitment
• Curriculum redesign or QI initiative that reports directly to leadership
• Task forces the chair announces at department meetings

This is where you get facetime and where people higher up see you functioning in a group.

If you quietly volunteer for one of these, do solid work, and make the leader’s life easier, your name will come up positively when the chair asks, “Who’s good? Who’s ready?”

3. Curate How You Show Up in Public Forums

Every talk, M&M, poster session, or grand rounds is part of your audition.

Basic stuff, but shockingly often ignored:

• Accept feedback on your slides and style without getting defensive
• Handle questions with “That’s a good point, here’s how I think about it,” not “Well actually…”
• Credit your team and mentors out loud

I’ve been in rooms where a chair turned to me after a resident talk and said, “They’re going somewhere. Let’s keep an eye on them.” That’s when the mental file starts to change.

4. Make Light, Periodic Contact With the Chair

No, you don’t storm their office weekly. That’s annoying.

You do:

• Send a short email once or twice a year: quick update, one concrete win, one line of gratitude for support from the department
• Say hello and one sentence of substance after grand rounds if the moment is right
• Ask for 15 minutes once a year to get advice on a specific fork in the road (not your entire life story)

You’re not asking for opportunities in those moments. You’re building the sense that you’re thoughtful, serious, and plugged in. So when something comes across their desk, your name is at least on the mental whiteboard.

5. Make It Easy for Others to Nominate You

A little‑known trick: a lot of chairs want to help. They’re just stretched thin. If they have to dig to remember what you’ve done, you lose.

So you maintain:

• A concise, updated bio and CV
• A few lines that make your “angle” clear (e.g., “My focus is equity in perioperative care,” not “I do some research”)

When your mentor says, “I want to put you forward to the chair for this travel award / committee,” you hand them something they can drop straight into an email.

People who are easy to nominate get nominated.

---

Why This System Isn’t Fair—And Why It Isn’t Going Away

Let me be blunt: this system systematically advantages:

• People who are naturally socially comfortable
• People with mentors already wired into the web
• People who look and sound like prior “success stories” in that institution

There is bias. Gender, race, accent, training institution, all of it. Chairs are human, operating under pressure, defaulting to patterns.

But here’s the uncomfortable other side: you cannot “policy” your way into a purely meritocratic allocation of every single opportunity. Too many of these decisions are fast, soft, relational judgments about risk and representation.

So your job is twofold:

1. Do good work. Obviously. None of this matters if you’re clinically unsafe or academically hollow.
2. Make sure the right people repeatedly see you as: safe, reliable, additive, and loyal enough that betting on you feels smart.

If you ignore the second part on principle, you will watch less talented people leapfrog you for the next decade. I’ve seen it happen to excellent, bitter, invisible people. Over and over.

Years from now, you won’t remember which specific award you got or missed. You’ll remember when you finally understood that the “big opportunities” weren’t random—they flowed along predictable, human channels. Once you see those channels, you can stop standing on the bank waiting and start wading in on purpose.

---

FAQ

1. I’m a resident with no research yet. Can I realistically get picked for anything “big”?

Yes, but you’re not getting the keynote at ATS next year. Your “big opportunities” at this phase are things like: being chief resident, being sent to a national resident leadership program, getting a slot to present at a key institutional conference, or being recommended to help on an important project. Focus on being clinically strong, reliably helpful, and visible in one or two meaningful departmental activities. That’s enough to get you on your chair’s radar.

2. What if my chair clearly has favorites and I’m not one of them?

That happens. A lot. Do not waste energy trying to become the favorite. Aim to become “unignorable” through consistent performance and visible contributions. Build relationships with division chiefs, program directors, and other senior faculty who can speak your name in rooms you’re not in. A chair with favorites will still distribute some opportunities more broadly—your goal is to be in the next ring, not in outer orbit.

3. How do I ask for opportunities without looking entitled?

You don’t email, “Can you put me on a big grant?” You say something like, “Over the next 1–2 years, I’d like to grow in X (teaching / QI / research). If anything comes across your desk where a resident/fellow/junior attending could be useful on that front, I’d be eager to be considered and to do the unglamorous work too.” That signals ambition and humility at the same time. Then you back it up with actual grunt work once you’re looped in.

4. If I mess up once—miss a deadline, have a bad talk—am I done?

Usually not, unless it was catastrophic or repeated. Chairs remember patterns more than one‑offs. The key after a screw‑up is to: own it without excuses, fix what you can, and then go on a streak of over‑delivering on smaller things. Over time, people’s mental model of you shifts back to “reliable.” The worst thing you can do is disappear out of shame; that cements the negative impression instead of rewriting it.