The changes that have occurred in academic medicine during the past few decades were largely unimaginable when I began my career roughly 30 years ago. At that time things were reasonably simple for a young faculty member embarking on an academic career. Since virtually all faculty endeavors were conducted within the organizational framework of traditional departments, lines of authority and responsibility for career development were well-defined and the rules governing career advancement were clear. Furthermore, faculties were relatively small, so it was easy to interact regularly with senior faculty who could provide advice and direction on how to build a successful academic career. And importantly, the patient care responsibilities of the clinical faculty were inextricably linked to the medical school's teaching and research missions. Thus there was no expectation that a new member of the faculty would be responsible for generating some or all of his or her salary by developing a clinical practice that would operate somewhat independently of those missions.
Today's reality is quite different! Medical schools have become extremely complex organizations in which each of the missions–education, research, and clinical care–is pursued to a great extent independently of the others. This is not necessarily a bad thing, provided, of course, that the institutions are organized and managed in ways that reflect the present reality rather than the reality of the past. With regard to the organizational structure of medical schools, David Korn, senior vice president for biomedical and health sciences research at the Association of American Medical Colleges (AAMC), argued several years ago that the traditional departmental structure of medical schools has probably served its purpose and that new approaches are needed for organizing the faculty so they could pursue the institution's missions more efficiently and effectively. The growing number of multidisciplinary centers and institutes being established in medical schools clearly reflects efforts to achieve this goal.
As this process continues, as it inevitably will, it is important that institutions pay careful attention to the policies and practices that affect the careers of their faculties. Since a medical school's most important asset is its faculty, it follows that the future of the institution depends to a great extent on the degree to which it is successful in nurturing the career development of the most junior members of the faculty. Many factors contribute to building a successful academic career. But what is most important is that junior faculty understand clearly what is expected of them and that they are provided opportunities to meet those expectations. In today's world, this means that they must be assigned responsibilities that are aligned closely with the specific mission they wish to focus on and that their career advancement is determined by how well they meet those responsibilities. This, of course, is the rationale for the growing practice of appointing faculty members to specific career pathways and for using different criteria in making decisions about the advancement of individuals within each pathway.
Four articles appearing in this month's journal provide additional insights into the faculty appointment, promotion, and tenure policies now in place in medical schools. Liu and Mallon describe the faculty appointment and tenure policies being used by basic science departments. The results of their study indicate that during the past decade those departments have increased markedly the use of nontenure-track appointments. This trend is in keeping with well-established practices for the appointment of both MD and PhD faculty in clinical departments. Since the use of nontenure appointments affects junior faculty disproportionately, it is reassuring to note that schools have also developed more flexible approaches for supporting the career development of junior faculty members in those departments.
Two of this month's articles–research reports by Thomas et al. and Howell et al.–demonstrate how the approaches being used for appointing faculty in clinical departments vary from institution to institution. The reports describe the policies in place at Johns Hopkins University School of Medicine and in the five medical schools of the University of California system. Johns Hopkins and several of the schools in the University of California system are among the most research-intense medical schools in this country and also sponsor large patient care and clinical training programs. Despite similarity in the size and scope of their mission-related activities, they have very different approaches for managing the career development of their faculties. Johns Hopkins has retained a single faculty-track system, while the University of California system has five different tracks to which faculty can be appointed.
Finally, Fairchild et al. suggest in their article that medical schools should establish a distinct track to support the career development of individuals who seek careers as administrators. Since the challenges facing academic medical centers have grown increasingly complex in recent years, more attention does need to be paid to the career development of those who aspire to leadership roles in those institutions. Given that, the authors raise an important issue for consideration by the current leadership of academic medical centers.
The information contained in the four articles reveals that a number of medical schools and their parent universities have recognized the need to develop and implement faculty appointment, promotion, and tenure policies compatible with the increasing complexity of academic medicine and the changing roles and responsibilities of medical school faculty. It is essential that such policies continue to evolve as those and other institutions establish new approaches for conducting their various missions. As this process continues, both the institutional leadership and the faculty councils that play a major role in establishing policies governing faculty affairs must recognize the need to protect and nurture the most junior members of the faculty. Those individuals, who represent the future of the institutions, are the ones most vulnerable to policies that fail to recognize the reality of current circumstances and remain wedded to an outdated conceptual framework about the contributions that faculty members pursuing different career paths make to the institution's overall mission.
Things have clearly changed since I started my academic career and they will continue to change over time. The old days when faculty members were expected to make meaningful contributions to more than one of the institution's missions, if not all three, are long gone. The simple fact is that medical schools need faculty members who excel as teachers and educators or as researchers or clinicians or administrators, and that to excel in one of these endeavors requires a faculty member to make an almost full-time commitment to it. The institutions’ faculty appointment, promotion, and tenure policies must be shaped to support the career development of individuals in each of these pathways, and special faculty development programs need to be implemented to assist faculty as they progress through their careers. The future of academic medicine requires that those crafting policies governing faculty career development recognize this. Even though there is more progress needed, the articles appearing this month provide reasons for being optimistic about the future.
Michael E. Whitcomb, MD