20% of people who get admitted to the hospital require readmission within 30 days of being discharged. Medicare has taken steps to reduce these readmissions, but the unintended consequence of...
Tenure [ten-yer] noun: Guaranteed permanent employment, especially as a teacher or lecturer, after a probationary period.
In academic medicine, the ultimate professional achievement is tenure. But what, exactly, is tenure? Historically, it meant that if you proved yourself, you got tenured and you were given academic freedom to do whatever research you wanted and the freedom to express your own opinions as an educator. And then, you would be protected from being fired.
The history of tenure in the United States.
In the 1800’s, professors served at the discretion of university’s boards of trustees who hired and fired them. But by the turn of the century, there was concern that this system led to influential donors dictating what professors could and could not research and teach. In 1915, the American Association of University Professors (AAUP) created a declaration of principles for academic freedom and tenure:
- Trustees raise faculty salaries, but not bind faculty with restrictions.
- Only committees of other faculty members can judge a member of the faculty.
- Faculty appointments be made by other faculty and chairpersons, with three elements:
- Clear employment contracts
- Formal academic tenure, and
- Clearly stated grounds for dismissal.
In 1940, the AAUP recommended that the probationary period before granting tenure should be 7 years. But the AAUP’s declarations did not provide academic freedom protection. In the McCarthy era, professors suspected of being communists could be fired and in the 1960’s, twenty states passed laws that professors who voiced anti-war sentiments could be fired from public colleges. Legal cases in the 1970’s helped to create protection from dismissal of tenured professors leading to the system that we have today, where tenured faculty are insulated (although not completely immune) from job termination and censorship.
Tenure track versus clinical track.
The problem with this is that it has created a caste system in academic medicine where physicians are either in the “tenure track” or the “clinical track”. If you are in the tenure track, you are promoted from “Assistant Professor” to “Associate Professor” and ultimately to “Professor”. When you are promoted to Associate Professor, you become “tenured”. However, if you are in the clinical track, you are promoted from “Assistant Professor, Clinical” to “Associate Professor, Clinical” and ultimately to “Professor, Clinical”. The clinical track faculty do not have the same rights as the tenure track faculty. You cannot be tenured in the clinical track and your contract is year-to-year rather than an indefinite duration.
Each department has a promotions and tenure committee that then reports to the college promotion and tenure committee that then reports to the university board of trustees. At each level, a faculty member who is up for promotion is voted on whether or not to be promoted.
But there is a problem with two academic tracks.
At the promotion and tenure committee levels, committee members who are in the tenure track vote on whether or not to promote both tenure track candidates and clinical track candidates. However, committee members who are in the clinical track can only vote on clinical track candidates. Inherent in this system is the assumption that tenure track faculty can judge the qualifications of clinical track faculty but clinical track faculty are incapable of judging whether tenure track faculty are qualified.
As a result, the criteria for promotion in the clinical track ends up looking a lot like the criteria for promotion in the tenure track. Being the best diagnostician or surgeon in the university does not get you promoted. Similarly, being the best teacher in the university won’t get you promoted. Even in the clinical track, you have to write articles about diagnoses and surgeries or write articles about teaching to get promoted. The clinical track in academic medicine has become in essence, the junior varsity track with the tenure track becoming the varsity track.
Last year, my son was doing campus visits as a high school senior when deciding where to go for college. At one university, which by all of the college ranking lists was among the top universities in the country for chemistry, the upper classmen that we met with told him that he should take his freshman chemistry courses at the 2-year community college on the other side of town and then transfer the credit because the professors that taught freshman chemistry were not as good of educators and were largely unavailable since their primary focus was their research rather than teaching undergraduates.
Our academic promotion values are out of synch with the needs of academic medicine.
The only way to get grants and write manuscripts is to have time during the week to do it. This has resulted in the concept of “protected time”, that is, time that you are not required to be seeing patients. The more protected time you are able to negotiate in your employment contract, the better your chances of being promoted, either in the tenure track or in the clinical track. One of the problems is that someone else has to pay for the cost of your salary during that protected time and that someone is often the physicians seeing patients full-time.
But to survive in the future, academic medical centers will not maintain financial viability purely by populating themselves with as many famous physicians as possible. Academic medical centers are increasingly in a vicious competition with private hospital systems for their very survival. If the academic medical center is not seeing enough patients, then it doesn’t have enough clinical income. And if it doesn’t have enough clinical income, it goes broke. So we are now in the difficult position of rewarding our academic physicians to to see fewer patients while we need our academic physicians to see more patients to stay in business. Our need priorities and our reward priorities are out of alignment.
So what do we do with tenure?
- Promote academic physicians for excellence in teaching. This seems so intuitive, so why don’t we do it? As an analogy, if you were hiring a contractor to remodel your kitchen, would you want the contractor who has the reputation as the best remodeler in the community or the contractor who writes a lot of articles in The Journal of Home Remodeling but had all negative reviews on Angie’s List? If our business is teaching medical students, why wouldn’t we value the best teachers?
- Promote academic physicians for excellence in clinical care. One of the best clinicians I have ever known spent 33 years as an Assistant Professor before retiring (as an Assistant Professor). He was known at Ohio State as “the doctor’s doctor” because all of the doctors who knew him wanted him as their doctor. If our business is taking care of patients, why wouldn’t we value the doctors who do the best job taking care of patients?
- Eliminate the caste system of tenure versus clinical tracks for promotion. Promotion and tenure committees should either be comprised of both tenure track and clinical track faculty who all vote on all candidates who are up for promotion or we need to have two entirely separate promotion systems: one comprised only of tenure track faculty who vote on exclusively tenure track promotion candidates and one comprised only of clinical track faculty who vote exclusively on clinical track promotion candidates.
- Eliminate the word “Professor” for academic physicians who are not in a tenure track. In some health systems, the physicians have other titles that better reflect their commitment and achievement in patient care. So maybe we’d be better off using consultant: “Assistant Consultant”, Associate Consultant”, and “Senior Consultant”. Or maybe clinician: “Associate Clinician”, “Senior Clinician”, and “Master Clinician”.
What did I do?
In 1997, I became tenured when I was promoted from Assistant Professor to Associate Professor in the tenure track. However, rather than feeling like I had academic freedom to do what I was passionate about, I felt constrained because in this track, I would not be able to do what I really enjoyed: teaching medicine, taking care of patients, and taking on administrative leadership roles in the hospital. Instead, the tenure track had me locked into a future of submitting research grants and writing journal articles. Don’t get me wrong, these are noble and valued activities and I had a lot of passion for them. Its just that I had even more passion about teaching and patient care. So in 2002, I resigned my tenure which meant that I actually had to resign from my job at Ohio State, and then was immediately re-hired as a “Professor – Clinical”, no tenure. And now, I have the best job in the medical center.
The whole idea of tenure was to protect university faculty from being fired because of their opinions and to give them the freedom to study the things that they were passionate about. But the unintended consequence of tenure is that in today’s academic medicine environment, the tenure process discriminates against those academic physicians whose passions are teaching and clinical care.
December 31, 2016