Academic Medicine

Do We Really Still Need A Tenure Track In Academic Medicine?

Tenure is defined as: “guaranteed permanent employment, especially as a teacher or lecturer, after a probationary period“. Ohio Senate Bill 83 is currently being considered by Ohio’s legislative body and would change tenure in Ohio’s colleges and universities. In current practice, tenure is usually reserved for those faculty who have proven their value to a college based on the number of research grants they have received and number of research articles that they have published. But is tenure still relevant in our nation’s colleges of medicine?

Summary Points:

  • Universities want tenured professors who are successful obtaining research grants and writing papers
  • Academic hospitals want clinical professors who practice the highest quality and often highly specialized patient care
  • We treat these two classes of faculty differently
  • It’s time to level the playing field and treat tenure track and clinical track faculty the same
  • Ohio Senate Bill 83 includes provisions to reduce privileges traditionally afforded to tenured faculty


Fifty years ago, most medical school faculty were either tenured or in the tenure track awaiting advancement to tenure. Once they received tenure, they were given academic freedom to take their research and scholarly activities in whatever direction they chose and it was exceedingly difficult to fire a tenured faculty member.

As an example, 30 years ago, a tenured physician member of my division lost his medical license due to recurrent alcohol and drug use. Without a medical license, he could no longer be a member of our hospital’s medical staff. However, because he was a tenured professor, he could not be terminated from the university so he continued to receive a salary despite no longer seeing patients, teaching students, or performing research. Due to the structure of the university’s salary plan, the funds for his salary had to come from the clinical income of the division, meaning that we all had to forgo bonuses and raises in order to pay the salary of a tenured professor who was no longer even coming into the office. This was a (fortunately rare) example of tenure gone awry.

Beginning about 40 years ago, there emerged a second track for physician faculty at U.S. colleges of medicine, most commonly called the “clinical track”. Unlike tenure track faculty, these clinical track faculty members had fewer requirements for research metrics such as grants and journal article publication. Instead, clinical track faculty primarily focused on clinical care of patients. Over time, these clinical track faculty also assumed most of the responsibility for teaching medical students and residents. What emerged in the 1990’s was a caste system in our nation’s universities with the clinical track faculty perceived as second class citizens. For example, at the Ohio State University, tenure track faculty can vote on promotion of clinical track faculty, however clinical track faculty cannot vote on promotion of tenure track faculty. In the past, only tenure track faculty could vote in elections to the University Senate, the governing body of the university and only tenure track faculty could run for Senate office. Tenured faculty receive a university appointment for life but clinical track faculty are only hired for periods of 3-5 years, after which, they have to be reappointed to maintain their employment.

Tenure track faculty are still favored over clinical track faculty at most American universities. For example, at Ohio State University, the Board of Trustees Bylaws and Rules number 3335-7-03 states that “Unless an exception is approved by the university senate and the board of trustees, clinical/teaching/practice faculty may comprise no more than forty percent of the total faculty in each of the colleges of the health sciences.” The implication is that clinical track faculty are less desirable than tenure track faculty. But the demand for faculty who perform patient care vastly exceeds the supply of tenured physicians. Consequently, the overwhelming majority of faculty in clinical departments of the OSU College of Medicine are in one of the clinical tracks and not in the tenure track. This is similar to most medical schools in the United States. Despite this trend, nearly all medical school deans and clinical department chairs in the U.S. come from the tenure track and not the clinical track.

As academic medical centers have grown larger, so too has grown the number of physicians needed at these hospitals to see patients and generate clinical revenue. At most academic hospitals, physicians have to have an academic appointment in order to be on the hospital’s medical staff. This has led to a rapid expansion in clinical track faculty at most colleges of medicine in the United States. It has also led to conflicting values between the universities and their associated academic medical centers: the university leaders (such as the presidents and deans) value tenure track faculty more highly whereas the hospital leaders (such as the CEOs and CFOs) value the clinical track faculty more highly. The rapid increase in clinical track physician faculty has also led to more subdivisions of the clinical track. When I first joined the Ohio State University faculty in 1991, there were only two options: tenure track or clinical track. Now, the clinical track has been subdivided into clinical educator, clinical scholar, clinical excellence, teaching, and practice pathways. In addition, there is an adjunct clinical faculty track for unpaid community physicians who participate in medical student or resident education. At other colleges, adjunct faculty are those who are paid by the college but are part-time faculty; in many undergraduate colleges, these adjunct faculty teach the majority of classes.

The result is that U.S. colleges now have two parallel tracks for promotion and career advancement. First, there is academic rank consisting of (1) instructor, (2) assistant professor, (3) associate professor, and (4) professor. Academic rank is used for both tenure track and clinical track faculty. It is a measure of seniority and academic accomplishment. Second, there is tenure. Tenure is only granted for tenure track faculty, typically when they advance from assistant professor to associate professor. Tenure grants the privilege of choosing one’s own scholarly activities and grants one a job for life. At issue is whether we really need both tracks or can we eliminate tenure and replace it with academic rank?

I would argue that this two-class system of academic medicine is harmful to the future of academic medicine. An academic physician in the clinical track who is treated like a second class citizen at the university can leave to work in a community hospital where he or she will be treated like a first class physician. If we don’t start treating our clinical track physicians like other faculty, then our academic medical centers will continue hemorrhaging the best clinicians to private practice.

In full disclosure, I began my academic career in the tenure track and was granted tenure in 1997 when I was promoted to associate professor. However, my academic identity was as a teacher and clinician. So, in 2002, I resigned my tenure and switched to the clinical track since medical education, patient care, and clinical research were more appropriate activities for clinical track faculty. As a professor in the clinical track, I still was able to choose what classes I taught and choose what clinical research studies to participate in. In this sense, I had academic freedom. The main difference for me was that unlike the professors in the tenure track, I had to be reappointed to my job every 5 years.

So, should one class of faculty be more privileged than another class?

Ohio Senate Bill 83 is a proposed legislation that, among other things, would alter how Ohio’s colleges and universities use tenure. One provision of the bill is that it would require universities to annually assess tenured faculty on several criteria, including teaching. Furthermore, 50% of the teaching assessment must be based on student evaluations and mandates that students evaluate each faculty member based on the question: “Does the faculty member create a classroom atmosphere free of political, racial, gender, and religious bias?” The bill further requires tenured faculty to undergo a post-tenure review if they have evaluations of “does not meet performance expectations”. The implication is that it would be easier for universities to fire tenured faculty members who have below average student evaluations. It has engendered a lot of debate and some of the fiercest criticism has paradoxically come from conservative professors who fear that they could lose their jobs due to poor evaluations from students who have more liberal or centrist views on political and social issues.

Senate bill 83 has some other controversial provisions. It prohibits colleges from having mandatory diversity training for employees. It prohibits any Ohio state-funded college from having any academic relationships with any academic institutions in China. It requires all Ohio undergraduate students to take a history or political science course and specifies the required reading materials for those courses. It mandates an enormous amount of reports and paperwork to be regularly submitted to the Chancellor. It prohibits colleges from using gender identity or sex to segregate student for residential housing. It specifies that no employee of a state institution of higher education can strike; this includes nurses and essentially anyone who works at an academic medical center.

Make no mistake about my opinions regarding academic medicine – we need medical scientists to do research to improve our ability to understand and treat disease. But we also need expert clinicians to oversee the care of our patients at academic medical centers. And we need the best teachers for our medical students and residents. There was a time when a single tenured academic physician could do all three of these mission areas effectively, the so-called academic “triple threat”. But those days are gone and true triple threat academic physicians are exceedingly rare as grant funding has gotten more competitive, as clinical care has become more specialized, and while teaching has remained time-consuming. Increasingly, the tenure track is primarily used for those faculty who do research whereas the clinical track is used for those faculty who primarily teach and take care of patients.

If our colleges of medicine really want to meet their tripartite mission of teaching, research, and clinical care, then we need to start treating those faculty involved in each of these mission areas equally. If we hire tenured faculty for an indefinite duration then we should hire clinical faculty for an indefinite duration. On the other hand, if we only hire clinical faculty for 3-5 year periods before reappointment, then we should only hire tenured faculty for 3-5 year periods.

Seven years ago, I wrote a post entitled “The Anachronism Of Tenure” that implied that tenure is a hold-over from a previous era of American academia. Increasingly, tenured faculty are the minority of our country’s academic physicians and increasingly, tenure is reserved for only those academic physicians whose primarily role is research. Ohio Senate Bill 83 is an attempt to diminish the special privilege that tenured faculty have enjoyed but I think that it misses the target. The original idea of tenure was to ensure academic freedom for the tenured faculty member. With the growth in the number of faculty members who provide clinical care and the shift in medical education resulting in non-tenured faculty teaching the majority of health science courses, tenure has evolved to mean additional privilege and job security afforded to faculty who do funded research.

It is time to call tenure out for what it really has become. It was originally created to provide job security protection for academic faculty to pursue scholarly activities. It is now primarily reserved for faculty who have been awarded the most research grants and who have published the most journal articles. Other measures of scholarly activity, such as effectiveness of teaching and (in the case of academic physicians) improving community health, are no longer considered grounds for tenure and are now mostly relegated to clinical track faculty. The recipe to achieve tenure is: don’t volunteer for anything, protect your time at all costs, and focus exclusively on getting published. The advice given throughout the country to physician assistant professors in the tenure track is that in order to make tenure, you have to see fewer patients, avoid committee assignments, and teach fewer classes so that you can spend more time writing papers.

It is time to show that U.S. colleges of medicine value all three mission areas equally. We need to either grant tenure privileges to those academic physicians whose primary responsibility is teaching and clinical care or we need to eliminate tenure completely. Some specific tactics that could realign these mission areas include:

  • Ensure equal representation and authority of both tenure track and clinical track faculty on promotion and tenure committees.
  • Equate the annual review process for tenure track and clinical track faculty. For example, a 1-year probationary period followed by a 3-year subsequent appointment period for all assistant professors, a 4-year appointment period for all associate professors, and a 5-year appointment period for all professors (for both tenure track and clinical track faculty). Reappointment periods would be for similar periods of time for each academic rank.
  • Equal eligibility of both tenure track and clinical track faculty to serve on university governing bodies.
  • Increase the representation of clinical track faculty in dean and department chair positions in our colleges of medicine and clinical departments.
  • Consider eliminating tenure altogether and transferring some of the job protection and privileges of tenure to academic rank, such as the ranks of professor and/or associate professor.

In my opinion, Ohio Senate Bill 83 is simply bad legislation. It creates a new layer of bureaucracy and paperwork, it restricts or eliminates collective bargaining processes, it meddles in foreign affairs that should be the jurisdiction of the U.S. State Department, and it mandates undergraduate classes that are already required for graduation from Ohio’s high schools. But part of the bill targets tenure at Ohio’s colleges and universities. Clinical departments comprised of academic physicians are different than non-clinical departments comprised of PhDs and the need for a privileged class of tenured faculty in our clinical departments may be less than in non-clinical departments. If we don’t fix the tenure issue at our medical schools ourselves, then legislative bodies like the Ohio Senate are going to fix it for us… and we may not like the result.

April 30, 2023


By James Allen, MD

I am a Professor Emeritus of Internal Medicine at the Ohio State University and former Medical Director of Ohio State University East Hospital