Promotional pathways for faculty at academic medical centers (AMCs) largely track along 3 missions: clinical care, research, and education. But this system has been under stress for years, with data showing that clinical faculty members are less likely to be at higher academic ranks, less satisfied with their progress on the promotion escalator, and more likely to leave or at least express an intention to leave academic medicine.1,2 The elephant in the room and the source of significant frustration for faculty is that the research mission is often accorded greater recognition and visibility at AMCs, evidenced in how the concept of tenure, with its associated reputational currency, is only granted to faculty members on this track.
To complicate things further, narrowing operating margins and declining federal research dollars have forced AMCs to restructure their operating models to better align with the goals of their affiliated hospital system.3 These strategic imperatives have led to important compositional changes in AMC physician faculty. For example, health systems, now leaning more heavily on the generation of clinical revenue to sustain their enterprise, have intensified hiring of clinical faculty members who are explicitly not on any promotion pathway. In many places, these faculty members are hired directly by hospitals and work without supervised trainees. There has also emerged a new breed of physicians—physician-executives—who manage efforts in population health, build up internal innovation centers, or lead strategic planning for health systems. Despite these physicians spending most of their time in service to the institution, their contributions are not easy to categorize, and many are relegated by default to the clinical track.
Thus, AMCs are increasingly saddled with an uneasy 2-class system of those on a promotion pathway and those off, those with a natural academic home and those without, those eligible for tenure and those not. In this article, we examine the history of the academic promotion and ask if it is time to jettison it.
Although the system of promotion and tenure that forms the backbone of AMCs feels like the beating heart of the academic faculty experience, the truth is that it is a relatively recent phenomenon.4 It was not until after World War II and long after the Flexnerian revolution of medical education (when medical schools began to affiliate more closely with universities) that the tenure system, developed originally for faculty in the arts and sciences, was coopted by medical schools. Places like Johns Hopkins led the way in hiring full-time physiologists and anatomists, whose income was supported by salary rather than private practice income. Certainly, this culture of research contributed to the subsequent explosive growth of biomedical knowledge in the 20th century.
However, physician faculty at medical schools have always had fundamentally different jobs than faculty members in the arts and sciences by way of their commitment to service. In their practice of their craft, patient care, medical school faculty members are without peers in the larger university system.5 In contrast, business school faculty members are not required to provide consulting services to companies, and law faculty members are not required to provide legal aid simply to keep the lights on. Thus, medical school faculty members have always had a dual identity of sorts, as purveyors of academic knowledge at the medical school and generators of revenue for the hospital. Furthermore, the concept of tenure has always been slightly irrelevant to clinicians. While tenure confers academic freedom on liberal arts faculty and thus the ability to espouse unpopular ideas without fear of immediate dismissal, there is no analogous protection given to clinicians. For instance, a tenured physician who voices antivaccination views may lose his or her job, notwithstanding the fact of tenure. Additionally, today’s physician faculty members, even those with tenure, must continue to see patients or secure research grants to make their salaries whole.6
As the scope of AMCs shifts, the current edifice of promotion and tenure starts to appear dated. Defenders of the status quo, however, usually use 1 of 2 arguments. The first is that not all work done at an AMC, despite being important, furthers the academic mission. This argument, which belabors the point that the ideal academic clinician be the perfect blend of research, clinical care, and education, is as unsatisfying as its underlying reductionist assumptions. To start, few clinicians are truly able to manage this juggling act without protected time within the workweek to meaningfully pursue all 3.7 Furthermore, it discounts the contributions of those whose work actually requires deep expertise; few aspiring physician-executives are landing in leadership positions today without concomitant degrees in management or public health, for example.
The second, somewhat associated counterargument, is that exclusion from the promotion pathway is not actually hurting anyone. This argument suggests that promotion up the ladder from assistant professor to associate and full professor positions is simply an academic nicety, a titular rather than financial benefit. But if a reward system is truly so toothless, should it be retained? Furthermore, this argument is actually quite disingenuous, given that many leadership roles within the health system (and without) are contingent on a candidate achieving a certain academic rank.
What would an alternative recognition system look like? Our suggestion: let us abandon strictly codified pathways and move toward more broadly recognizing excellence (possibly as voted by a plurality of one’s peers). After all, excellence comes in many varieties, from providing excellent patient care to the formulation of new theories, teaching, engaging in quality improvement, and academic leadership. As long as a faculty member demonstrates consistency in excellence, it should not matter what form it takes. A move away from specificity in requirements for promotion and toward generality in recognizing excellence accomplishes several things; it accounts for the heterogeneity in faculty output; acknowledges the increasing impossibility for a faculty member to do it all with respect to teaching, research, and clinical service; and still remains enough of an external validator to motivate faculty members to distinguish themselves. At a time when AMCs are competing to retain the best and the brightest, it is time to broaden the tent of internal recognition.
Open Access: This is an open access article distributed under the terms of the CC-BY License.
Corresponding Author: Samyukta Mullangi, MD, MBA, Division of Health Care Delivery Science and Innovation, Weill Cornell Medicine, 402 East 67th St, LA 202, New York, NY 10065 (firstname.lastname@example.org).
Conflict of Interest Disclosures: Dr Blutt reported personal fees from Consonance Capital, Bako, Psychiatric Medical Center (PMC), and Kepro outside the submitted work and membership on the board of the Commonwealth Fund, board of overseers of Weill Cornell Medicine, board of overseers of the Wharton School, and board of overseers of the School of Arts and Sciences at the University of Pennsylvania. No other disclosures were reported.
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Mullangi S, Blutt MJ, Ibrahim S. Is it Time to Reimagine Academic Promotion and Tenure? JAMA Health Forum. 2020;1(2):e200164. doi:10.1001/jamahealthforum.2020.0164