Within academic medical centers, psychiatry, pediatrics, and certain other specialties of internal medicine carry a disproportionate responsibility for teaching but are least able to support teaching and research through clinical income. This article reviews the educational, research and clinical missions of an academic psychiatry department and the major challenges facing chairs as they seek to lead their departments. Though the leadership role that the chair plays in psychiatric education, research, and clinical services can be tremendously satisfying, it is also true that being a chair in these times has much in common with "middle management" in other corporate structures.