Kahn, Jessica A. MD, MPH; Degen, Sandra J. F. PhD; Mansour, Mona E. MD; Goodman, Elizabeth MD; Zeller, Meg H. PhD; Laor, Tal MD; Lanphear, Nancy E. MD; Boat, Thomas F. MD
The demographics of academic medicine have changed significantly over the past several decades. By the end of the 1990s, 25% of medical school faculty were women; about 50% of these women were married to other physicians and 80% had or were going to have children.1,2 Many women delay childbearing until they complete their training. Therefore, those who pursue academic careers may be starting their research careers at the same time they are starting families and perhaps also caring for elderly relatives.3 In a study of internal medicine faculty, over 90% of part-time female faculty members were raising children.4 Although women in academic medicine may experience specific challenges related to work–life balance because they typically take on more caretaking responsibilities for children as well as ill or disabled relatives,2,5–7 male faculty—especially those with dependent children—have also reported feeling torn between their work and family responsibilities.8 In addition to caretaking responsibilities, both male and female faculty members may wish to devote time to other professional or personal activities. Thus, an increasing number of academic faculty desire more flexible and/or part-time work schedules.4
The proportion of part-time pediatricians in academic settings is low,9 especially in comparison with faculty in other university settings,10 and few part-time academic pediatricians have achieved the rank of associate professor or professor. A study published in 2002 estimated that among departments of pediatrics, 14% of total faculty worked part-time (defined as > 0.5 but < 1.0 full-time equivalent) and of these part-time faculty, only 8% were associate professors and 9% professors.9 Because a proportion of these part-time academic faculty work primarily in private practices or other nonacademic settings, the percentage who devote their full professional effort to academic positions may be even lower.
Institutional policies may explain in part the low proportion of part-time faculty in pediatric academic settings and their relatively low academic rank. Policies may specifically preclude faculty from working part-time or restrict the participation of part-time faculty in certain academic tracks, including the tenure track.11 In fact, part-time faculty have been shown to be more likely to participate in clinical tracks than research tracks. Clinical tracks were introduced to allow more flexibility for promotion of clinicians and educators, but are often perceived as less prestigious than research tracks and may not allow for attainment of tenure.12 A survey of all U.S. medical schools in 1994 demonstrated that less than half allowed part-time faculty to be on the tenure track and of those, only 61% allowed faculty to extend time to tenure on a prorated basis.13
Perceived attitudes about part-time faculty may also contribute to the low percentage of part-time faculty and their underrepresentation at high academic ranks. A study of academic department chairs demonstrated that although most chairs reported being very or extremely satisfied with part-time faculty and noted several advantages to employing part-time faculty, some believed that part-time faculty may be less committed to the institution, may not be as likely to share departmental goals, and may be less productive or accomplished than full-time faculty.11 Thus, academic faculty may choose not to work part-time because they are concerned that they would be perceived as less committed to their institutions and less productive than full-time faculty, and thus would be less likely to be promoted.
An examination of the attitudes of pediatric faculty regarding part-time work and the factors contributing to these attitudes may provide insight into why relatively few academic pediatricians work part-time, and why such a small proportion of associate professors or professors work part-time. Therefore, in our study we aimed to assess faculty members’ reasons for part-time work, attitudes about part-time faculty, and attitudes about institutional policies that would support part-time faculty among academic pediatric faculty; and to identify physician characteristics associated with specific attitudes about part-time faculty.
In 2001, we mailed an anonymous questionnaire to all 441 faculty members at Cincinnati Children’s Hospital Medical Center in Ohio. The faculty is diverse and consists of clinicians, researchers, and educators. Although the percentages vary year to year, approximately one-half hold an MD, one-third a PhD, and 10% an MD/PhD. A seven-member committee charged with formulating recommendations that would support part-time faculty created the questionnaire. All authors except TFB served on the committee. Several of the items for the questionnaire were adapted from surveys of internal medicine and pediatric faculty.4,8 Members of the committee, male and female faculty members of various academic ranks, division directors, and the department chair reviewed the questionnaire, which was revised based on their comments. The hospital Institutional Review Board approved the questionnaire. We considered respondents’ return of the questionnaire as their consent to participate. We mailed the questionnaire to all faculty members twice over a one-month period.
The questionnaire’s introduction specified that we sought to assess opinions about part-time, full-professional-effort faculty; that is, faculty whose full professional effort is directed toward the hospital and who are eligible to and/or likely to return to full-time status at some point.13 Domains covered by the 26-item questionnaire included demographic and professional characteristics, current part-time or full-time status and reasons for or against part-time work, and attitudes about part-time faculty. First, we assessed attitudes about the commitment of part-time faculty; for example, whether division directors or colleagues would consider part-time faculty less committed to the institution or to their careers. Second, we assessed attitudes about policies that would support part-time faculty; for example, whether part-time faculty should be allowed to carry the same titles as full-time faculty, whether they should be eligible for all academic tracks, and whether they should be able to extend time to obtain tenure. Finally, we assessed beliefs about the outcomes of policy changes that would support the reappointment and promotion of part-time faculty; for example, whether these policies would enhance recruitment and retention of a diverse faculty and whether they would improve the recruitment, retention, and promotion of female or male faculty. Responses to items assessing attitudes were given on a five-point scale (5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree, 1 = strongly disagree). In one open-ended item, we requested participants to comment on institutional efforts that would facilitate part-time careers for faculty and on other issues regarding part-time faculty. At the time of our study, part-time faculty at our institution held a different title than full-time faculty (“adjunct”) and were ineligible for the tenure track.
We analyzed the quantitative data using SPSS software, version 11.0 (SPSS Inc., Chicago, Illinois). Differences in attitudes about part-time faculty (analyzed as ordinal variables) by age (dichotomized into ≪ 45 years and > 45 years), gender, dependent child status, and academic rank (analyzed as categorical variables) were assessed using the Wilcoxon rank sum test. We used a Bonferroni correction to adjust the alpha level for multiple comparisons (adjusted p value = .05/number of comparisons) and in the results section and tables, the adjusted p values define significant associations. We performed multivariable analysis using linear regression in order to identify variables independently associated with specific attitudes about part-time faculty, and explored interaction terms between independent variables that were significantly associated.
Responses to the open-ended item requesting suggestions for institutional efforts to facilitate part-time careers were entered verbatim into a master document to facilitate content analysis. Seven of us (JAK, SJFD, MEM, EG, MHZ, TL, NEL) analyzed these qualitative data. First, we read through transcripts several times and independently listed key ideas and recurrent concepts.14 We then met twice to discuss the key ideas and concepts, categorize them, and create a framework within which the data could be organized. During this process, we drew from a priori issues that were assessed in the questionnaire and from new concepts noted by respondents. Finally, one of us (JK) placed text from the questionnaires (i.e., direct quotations) within the framework, and the investigators met a final time to review the framework and reach consensus on placement of quotations.
A total of 300 faculty members returned questionnaires (68%). Respondents’ characteristics are shown in Table 1. One hundred seventy-six (59%) respondents were male and 152 (51%) were age 45 or younger. Eighty (27%) respondents devoted most of their effort (i.e., ≫ 75% effort) to research, 49 (16%) devoted ≫ 75% effort to clinical work, and 9 (3%) devoted ≫ 75% effort to teaching. Respondents differed significantly from faculty as a whole by academic rank but not by gender: 105 (35%) respondents versus 81 (27%) of all faculty members were professors (p = .001), and 123 (41%) respondents versus 111 (37%) of all faculty members were female (p = .15).
Twenty-nine (10%) respondents currently had part-time appointments at the hospital. Those who worked part-time were more likely to be older than 45 years compared to 45 years or younger (21 [72%] versus 8 [28%], p = .01). Reasons given for working part-time, not working part-time, or considering part-time work are shown in Table 2. The most common reason given for working part-time was dependent children. Those who worked part-time because of dependent children were more likely to be women than men (11 [100%] versus 0 [0%], p < .001), 45 years or younger compared to older than 45 years (7 [64%] versus 4 [36%], p = .001), and lower compared to higher academic rank 95 [83%] instructors/assistant professors, 6 [75%] associate professors, and 0 [0%] full professors, p < .001).
Reasons given by full-time faculty for not working part-time tended to differ by respondents’ gender, age, dependent child status, or academic rank. For example, concern about the effect of part-time work on promotion was more likely to be reported by women compared to men (36 [57%] versus 27 [43%], p = .001), by those 45 years or younger compared to those older than 45 years (55 [87%] versus 8 [13%], p < .001), and by those of lower compared to higher academic rank (48 [44%] instructors/assistant professors, 14 [20%] associate professors, and 1 [1%] professors, p < .001). Of those working full-time, 88 (33%) had considered part-time work. These respondents were more likely to be women than men (57 [66%] versus 30 [35%], p < .0010, 45 years or younger compared with older than 45 years (55 [63%] versus 32 [37%], p = .048), and of lower academic rank (45 [43%] instructors/assistant professors, 25 [36%] associate professors, and 16 [19%] professors, p = .003). Those who had considered part-time work because of dependent children were more likely to be women than men (40 [77%] versus 12 [23%], p = .007], 45 years or younger compared with older than 45 years of age (43 [83%] versus 9 [17%], p < .001), and have lower compared with higher academic rank (35 [79%] instructors/assistant professors, 11 [42%] associate professors, and 6 [35%] professors, p = .001). Those who had considered part-time work because of retirement were more likely to be men than women (5 [83%] versus 1 [17%], p = .018).
Many faculty members were concerned about perceptions of part-time faculty. Up to 138 (46%) of faculty agreed that division chiefs or colleagues considered part-time faculty less committed than full-time faculty to their work. However, attitudes about policies supporting part-time faculty generally were positive: 192 (64%) agreed or strongly agreed that part-time faculty should carry the same titles as full-time faculty; 208 (69%) that part-time faculty should be eligible for all academic tracks, including the tenure track; 218 (73%) that part-time faculty should be allowed extension of the time allowed for tenure; and 276 (92%) that part-time faculty should be eligible to serve on committees. Differences in attitudes by gender, age, dependent child status, and academic rank are shown in Table 3. Several attitudes differed by gender: women, compared with men, were more likely to report that part-time faculty should hold the same titles as full-time faculty, that part-time faculty should be allowed extension of time to tenure, and that their division director and other faculty consider part-time faculty less committed to their careers.
Respondents agreed that the following outcomes could result from policy changes that specifically support the reappointment and promotion of part-time faculty: 258 (86%) ability of faculty members to achieve a better balance between work and family, 233 (78%) recruitment, retention and promotion of female faculty, 215 (72%) recruitment and retainment of a diverse faculty, 213 (71%) perception in the academic community that the institution is taking a leadership role in the area of supporting work-life balance, and 89 (30%) recruitment, retention and promotion of male faculty. Beliefs about outcomes did not differ significantly by respondents’ gender, age, dependent child status or academic rank when the Bonferroni correction was applied to adjust p values (see Table 3).
Multivariable linear regression models using seven specific attitudes about part-time faculty as the dependent variables were adjusted for respondents’ age, gender, dependent child status, and academic rank. Models demonstrated consistently that female gender and dependent child status were the variables independently associated with attitudes about part-time faculty (see Table 4). We added interaction terms separately to each of the seven models for age × gender, age × dependent children, age × rank, and gender × rank. Only two of these 28 models yielded significant interaction terms, and both were in the model in which the dependent variable was attitude about part-time faculty extending time to tenure. The two significant interaction terms were age × rank (β coefficient = .747, standard error [SE] = .205, p < .0001) and gender × rank (β = .314, SE = .155, p = .044). In the model including the age × rank interaction term, beta coefficients associated with gender, dependent child status, age and rank were significantly associated with the dependent variable. In the model including the gender × rank interaction term, gender was no longer associated with the dependent variable. We therefore stratified the sample by rank, and found that gender was a significant predictor of this attitude only among associate professors (β = .773, SE = .205, p = .003) and professors (β = .909, SE = .252, p < .0001), but not among instructors/assistant professors (β = .275, SE = .182, p = .134).
We classified responses to the open-ended items into a framework containing seven content areas (see Table 5). A total of 116 comments focused on institutional changes that would facilitate part-time careers and the importance of supporting part-time faculty; however, 14 comments expressed concern about policies that would support part-time faculty and the role of part-time faculty in the institution.
Respondents noted that in order for part-time faculty to succeed, expectations for productivity must be adjusted and clearly defined by supervisors. Respondents stated that part-time faculty should be allowed additional time to achieve a certain level of productivity, but should fulfill the same requirements for promotion and tenure as full-time faculty, and suggested that specific policies regarding these productivity expectations would be helpful. Others mentioned that expectations should be clarified regarding participation in divisional and departmental activities and financial compensation (e.g., compensation should be appropriate to workload and productivity). In contrast, several respondents expressed concerns about the ability of part-time faculty to achieve a level of productivity necessary for a successful research career, suggesting that the number of part-time faculty positions should be limited and that part-time faculty should serve primarily in clinical positions and should not be eligible for certain leadership positions.
Many respondents also suggested that institutional attitudes or “culture” must change if part-time faculty are to be successful, pointing out that part-time faculty are perceived as less valuable, less committed, and less productive than full-time faculty. They proposed that part-time faculty should be judged by their supervisors and peers based on individual merits and productivity rather than number of hours worked, and should be involved in policy decisions regarding part-time work. The comments of several other participants confirmed these perceived negative attitudes, especially those related to commitment. One respondent stated, “I think the institution needs the commitment brought by full-time faculty status…our issues and decisions are complex and require more than part-time attention.” Another asked, “Why should a part-time employee worry about tenure? It is obvious that their personal commitments outweigh their professional interests.”
Modifying institutional policies was also seen as important to ensuring the success of part-time faculty. Some noted that the institution should ensure that part-time positions and positions with flexible hours are available. Others focused on tenure-track policies, stating that part-time faculty should be allowed to be on the tenure track and should be able to extend the time allocated to achieve tenure. At the time the questionnaire was administered, part-time faculty at our institution carried an “adjunct” title, and several respondents suggested that the adjunct title be dropped and that part-time and full-time faculty should have the same titles, noting that the word “adjunct” had negative connotations.
Enhancing institutional resources was also given as an important factor in ensuring the success of part-time faculty. Suggestions focused on expanding the on-site daycare, providing care to ill children, and improving institutional mentoring. Finally, several respondents noted that allowing for part-time positions was essential to ensuring the recruitment and retention of talented faculty members. One noted that part-time positions would allow a faculty member with family responsibilities to continue work in academics and return to full-time work when their responsibilities change, rather than leaving the institution for private practice.
Although a relatively small number of pediatric faculty members in our institution in 2001 worked part-time, many more had considered part-time work. Those who had considered part-time work were more likely to be female than male; however, 30 (19%) male faculty members had considered a part-time position. A survey that examined trends in part-time work among U.S. pediatricians and consideration of part-time work among pediatric residents demonstrated that the percentage of practicing pediatricians working part-time increased between 1993 (11%) and 2000 (15%), and that the increase appeared to be due to the simultaneous increase in the number of women entering pediatrics.15 Female pediatricians in that study were more likely than were male pediatricians to work part-time, and they were twice as likely to work part-time as the female faculty in our institution. Part-time positions may be offered more routinely in private practices than in pediatrics academic institutions, where faculty may need to develop their own part-time positions; in a study of part-time internal medicine faculty, 64% of women reported developing the part-time position themselves.4 In addition, women who wish to work part-time may be more likely to choose private practice, possibly because they believe it would be difficult to find a part-time position in academic medicine or to succeed in academic medicine while managing family responsibilities.
Faculty may choose to work part-time in order to care for children or elderly relatives, to pursue other professional interests, or to create time for personal interests. Allowing faculty the flexibility to pursue these activities may enhance job satisfaction and decrease stress related to work-life balance. In fact, a study of U.S. physicians demonstrated that part-time physicians were significantly more satisfied than were full-time physicians with patient care issues, personal time, administrative issues, and their jobs; they also reported significantly less stress than did full-time physicians.16 Reasons given by our respondents for choosing or considering part-time work differed by gender; for example, all 11 respondents who worked part-time because of dependent children were women, while only 2 (22%) of those who worked part-time because of retirement were women. Reasons for part-time work reported by our respondents were consistent with reasons reported in a previous study of part-time internal medicine faculty.4 In that study, female internal medicine faculty reported involvement with children, time for family, better work–life balance, and more time for personal pursuits as advantages to part-time work, while male faculty reported satisfaction from teaching, ability to keep up with developments in their field, and involvement with academic pursuits as advantages.4 Based on these findings, it is not surprising that female faculty members who are raising children may choose to leave academic medicine if they are not able to pursue part-time work or are not successful in their efforts to be promoted: a survey of academic faculty regarding work environment demonstrated that 51% of women stated that work-family conflicts were the reason that they had seriously considered leaving academic medicine.17 These findings may explain why part-time faculty are less likely than are full-time faculty to achieve high academic rank.
Concerns about part-time work reported by faculty in our institution included adverse effects on academic productivity, promotion, and salary; negative perceptions about personal commitment; and uncertainty about availability or access to part-time positions in their divisions. The concerns about productivity and commitment are similar to those reported by part-time internal medicine faculty, most of whom worked as clinicians or teachers in nontenure-track positions.4 Although respondents in that study reported high career satisfaction, they believed that their part-time status made promotion more difficult and negatively influenced colleagues’ perceptions of them. Similarly, a study of department chairs’ attitudes about part-time faculty demonstrated that although chairs recognized the contributions of part-time faculty (such as keeping talented people in the workforce who might otherwise leave), they were concerned that part-time faculty would be less academically productive and would not share the goals and values of the department.11 Although little is known about the actual productivity of part-time versus full-time academic faculty, studies of clinicians do not support the assumption that part-time faculty are less productive. A study of physicians affiliated with academic primary care networks demonstrated that the clinical productivity of part-time physicians was actually greater than that of full-time physicians. Furthermore, rates of compliance with screening guidelines, resource utilization, and patient satisfaction did not differ for part-time compared with full-time physicians.18
In our study, female gender and dependent child status predicted agreement with policies that would support part-time faculty and concerns about part-time work, particularly negative perceptions about part-time faculty among division directors and other faculty. Differences in perceptions about part-time work based on gender and dependent child status have been noted in previous studies: 48% of female internal medicine faculty, compared to 12% of male faculty, believed that working part-time would adversely affect their colleagues’ impression of their commitment to their job.4 Both women and men noted that disadvantages to part-time work included high expectations and lack of respect from colleagues and the medical community. However, women cited as disadvantages limited career advancement, limited or no benefits, and doing as much work as full-time faculty, while men cited low salary and conflicting demands on time.4 One reason why women were more concerned about the negative impact of part-time work may be a lack of appropriate role models and mentors. Few high-ranking female faculty members who have worked part-time are available to give advice and mentoring to young faculty members. In addition, there may be differences in institutional as well as personal support available for women with children (who comprise most of those women who work part-time), compared to men with children. A survey of faculty from 24 U.S. medical schools demonstrated that female faculty with children, compared to male faculty with children, reported greater obstacles to academic careers and less institutional support, including receipt of research funding from their institutions and secretarial support.19 In contrast, receipt of institutional research funding and secretarial support was similar for women and men without children. Compared to men with children, women with children had fewer publications, even after controlling for number of years as a faculty member, number of hours worked per week, and hours of dependent care responsibilities. In addition, women with children perceived slower career progress and lower career satisfaction. Again, there were no significant differences in these outcomes between male and female faculty without children. Explanations for these differences might include less institutional support given to women compared to men, or greater dependent care responsibilities assumed by women despite a similar amount of time allocated to professional responsibilities.
Although many faculty members in our study expressed concerns about part-time work, most endorsed policies to support part-time faculty, such as eligibility for all academic tracks and extension of time to obtain tenure. The majority of our respondents reported that policy changes to support part-time faculty would enhance recruitment, retention and promotion of a diverse faculty. Faculty suggested that in addition to policy changes, part-time academic careers would be facilitated by clarifying expectations for productivity, changing institutional “culture,” and enhancing resources. Similarly, internal medicine faculty in another study reported that extension of time to tenure, change in attitude toward part-time faculty, clear criteria for advancement of part-time faculty, job-sharing opportunities, and resources (such as sufficient salary and on-site child care) would facilitate part-time careers.4
These suggestions also are reflected in the findings of a survey of female faculty at Stanford University School of Medicine, who ranked the following needs highest: a flexible work environment without negative consequences for women with young children, a three-month sabbatical from clinical and administrative duties, departmental mentoring for academic career development, and school/departmental administrative secretarial support for grant and manuscript preparation.20 The findings of these and other studies suggest that efforts to support part-time faculty should be comprehensive and include policy changes that support the promotion of part-time faculty, clarification of expectations for part-time faculty (e.g., periodic evaluations that take into account part-time status and delineate appropriate expectations for productivity), attitudinal changes at the institutional and divisional levels, and enhanced resources such as mentoring and administrative support. Cincinnati Children’s Hospital Medical Center used our study findings to formulate and implement recommendations: a policy was adopted allowing part-time faculty to be on the tenure track and extend time to achieve tenure, and the “adjunct” title for part-time faculty was dropped. In order to effect these changes, it was important first to gain the support of the medical school’s leadership. Our results were one of the most helpful mechanisms for gaining this support, because they provided quantitative data demonstrating that faculty were generally supportive of policy changes.
Our study had several limitations. We surveyed the academic faculty at only one hospital, which could limit our study’s generalizability to the larger academic community. However, the number of faculty has grown substantially in recent years from national and international recruitment; thus, the attitudes are not likely to be regionally biased. It is possible that respondents differed from nonrespondents in terms of attitudes about part-time faculty, although our response rate was relatively high (especially given the methodology and the time pressures that departmental faculty face). Although we found that faculty of higher academic rank were somewhat overrepresented among respondents, those who reported part-time work were reflective of the department as a whole. Despite these limitations, our study provides new and relevant information about attitudes regarding part-time faculty. To our knowledge, it is the first study designed to examine attitudes about part-time work among academic pediatricians, and the first to assess these attitudes in a sample of full-time as well as part-time academic faculty.
In conclusion, there will likely be increasing demand for part-time positions in pediatrics academic institutions, especially as the proportion of women in pediatrics increases.21,22 In order to attract, retain, and ensure the success of talented female and male faculty, academic institutions should create and enforce policies and systems to support part-time faculty.
This study received funding from the Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.