Levinson, Wendy MD; Rothman, Arthur I. EdD; Phillipson, Eliot MD
Dr. Levinson is professor and chair of medicine, Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.
Dr. Rothman is professor, Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.
Dr. Phillipson is professor and past chair, Department of Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada.
Correspondence should be addressed to Dr. Levinson, University of Toronto, R. Fraser Elliott Building, 190 Elizabeth St., Third Floor, Room 3-805, Toronto ON, Canada M5G 2C4.
Academic promotion has traditionally been based on research and teaching, but faculty members’ contributions to the profession may not be fully captured in those dimensions. Faculty members may influence the practice of medicine and improve the care of patients yet not obtain traditional measures of achievement through publications, grants, or teaching awards. With this problem in mind, at the University of Toronto Faculty of Medicine, the promotions committee developed and implemented a promotions criterion called Creative Professional Activity (CPA) to recognize and reward a variety of types of academic endeavors that have a demonstrable impact on medical practice and care. CPA comprises three activities: professional innovation, exemplary practice, and contributions to the development of the discipline.
In this article, the authors define CPA, provide illustrative case examples, describe how faculty members document CPA, and report the use of this promotions criterion in the Department of Medicine over the last decade. The challenges of implementing CPA as a promotion criterion are described. CPA is consistent with the Department of Medicine’s goal of achieving excellence through original research, education, or creative work that advances the care of patients.
Academic promotion of university faculty members, including clinical faculty, has traditionally been based predominantly on research accomplishments, with considerably less weight being given to teaching and professional contributions. During the past decade, however, medical schools have developed methods to measure and evaluate the accomplishments of clinical educators, thereby facilitating their academic promotion.1–7 The use of the new teaching assessments has complemented the traditional measures by which research contributions have been evaluated. Despite these changes, in another area, faculty members’ contributions to the practice of medicine have not been fully recognized for purposes of promotion. Specifically, significant gaps still exist in measuring and rewarding the contributions of faculty members who advance the practice of medicine by various means that have a demonstrable impact on medical practice and care. These faculty members conduct what Boyer8 calls the scholarship of integration, which interprets, draws together, and brings new insights to bear on original research. While their contributions can, and do, have a profound impact on the practice of medicine, traditional evaluations of research and teaching do not adequately address these activities. As a result, clinical faculty members who spend much of their time advancing the practice of medicine are at a disadvantage in the promotions processes in most medical schools.
Recognizing this deficiency over ten years ago at the University of Toronto, Faculty of Medicine, we developed and implemented a promotion criterion referred to as Creative Professional Activity (CPA). This criterion provided a platform for promotion on the basis of contributions to the advancement of medical practice. Because the introduction of CPA meant there were now three criteria (research, sustained excellence in teaching, and CPA) that could be used for promotion, the education of both faculty members and promotion committee members was necessary to implement CPA. In this article, we describe the components of the CPA promotion criterion and report the impact of this platform on academic promotions in the Department of Medicine at our school during the past nine years.
What is CPA?
The concept of Creative Professional Activity is based on the notion that certain types of professional activity encompass attributes of scholarship. The key word in this term is creative, but in assessing CPA as a basis for promotion, there must be evidence that the body of work has not only been creative, but has had an important impact on practice. Unlike the research criterion, evidence of dissemination or impact does not necessarily require research publications. Creative work can have an impact through a variety of forms including practice guidelines, professional organization recommendations, presentations in high-profile settings, or health policy changes. CPA comprises three related, but distinct activities: professional innovation, exemplary professional practice, and contributions to development of the discipline. Promotion can be based on any one element or on a combination of elements.
Professional innovation encompasses the notion that a faculty member may introduce or disseminate a novel technology, process, or concept, without necessarily having been personally involved in development of the product. For example, a clinical faculty member in our department introduced a novel catheter for renal dialysis and tested its effectiveness in clinical practice, without having played a role in “inventing” the technology. Having gained experience in its use, he then wrote guidelines for use of the new catheter and promulgated its uptake in clinical practice through presentations at professional meetings and peer-reviewed “state of the art” publications. These publications did not meet the traditional criteria of original research papers, but were scholarly, analytical, and integrative. Thus, the faculty member’s innovation was the introduction and dissemination of a new technology in the management of a common clinical problem.
Exemplary professional practice
Exemplary professional practice implies that the clinical activities of a faculty member are not only worthy of being copied, but have in fact been emulated by students and colleagues to the point that the individual has become a role model within the profession. The element that is considered exemplary may be related to the methods, style, or ethics of practice. In assessing exemplary professional practice, there must be evidence that the practice and behavior have indeed been emulated by members of the larger community of physicians. For example, a faculty member in our department developed a novel clinic to care for adult patients with cystic fibrosis who had previously been managed at a pediatric hospital. Under her leadership the adult clinic brought together, in a highly integrated program, members of several health disciplines (medicine, nursing, nutrition, physical therapy, and psychology), as well as researchers in the basic science, clinical, and epidemiological aspects of cystic fibrosis. In addition, the clinic became an important training site for residents and fellows. The key evidence for promotion in this faculty member’s CPA dossier was national and international recognition of the innovative care model for adults with cystic fibrosis, and the fact that the model had been emulated by other centers. Indeed, numerous health care workers from other jurisdictions had visited the clinic, and the leader had been invited to give presentations at a variety of international forums. In addition, although she did not serve as the lead author on research studies emanating from the clinic, it was clear that the research would not have been feasible without the clinical platform that she created.
Contributions to development of the discipline
The third type of CPA is contributions to development of the discipline. Such contributions can be demonstrated by a variety of professional activities, often through leadership roles in professional organizations or in government or regulatory agencies that have influenced the standards or enhanced a discipline. Occupying an executive position in an organization, while commendable, would not in itself be grounds for promotion. Rather, providing leadership within the organization that contributes significantly to the discipline would be required. Included in this category would be leadership in gaining formal recognition of a new subspecialty, in development of health policy, and in creating important consensus conference statements. For example, a faculty member in our department was instrumental in enhancing the profile of a medical subspecialty, bringing it into the mainstream of clinical medicine, and having it recognized as a formal subspecialty by the certification authority in Canada. Another faculty member, as leader of a national organization, developed recommendations for new safe approaches to transfusion of blood products. He worked with Canadian Blood Services and other agencies to disseminate these new recommendations and set new standards in operation of national blood systems.
Key to each of the three components of the CPA criterion is a body of work that is creative and innovative and has been demonstrated to have had an impact on the profession. As is the case for promotion on the basis of research or teaching, candidates being considered for promotion to associate professor on the basis of CPA must have evidence of a national reputation, and those being assessed for professor must have an international reputation. Hence there must be adequate appreciation outside the local environment of the impact of a faculty member’s creative work.
How do faculty members document their accomplishments?
Most medical schools are now familiar with the “teaching dossier” as a means of documenting teaching activities. In similar fashion, faculty members likely to seek promotion on the basis of CPA, maintain a “CPA dossier,” in addition to traditional curriculum vitae. Both documents contribute to the promotions process. The CPA dossier consists of the evidence and supporting documents that describe the creative work and its impact Items in this portfolio might include non-peer-review or lay publications, reports created for government or regulatory bodies, consensus conference proceedings, and documentation of foreign visitors’ coming to Toronto to learn from the faculty member. The scope of documentation is wide, since the nature of the creative activity can be broad.
How effective is CPA as a basis for promotion?
The Department of Medicine of the University of Toronto Faculty of Medicine includes 470 full-time faculty members. During the nine-year period of 1997–2005, 184 faculty members were promoted to associate professor or professor. Of these, one half were promoted predominantly on the basis of research, one quarter on sustained excellence in teaching, and one quarter on CPA (see Table 1).
The three promotions platforms (research, teaching, CPA) are available to any faculty member independent of his or her specific job description. Typically, however, faculty members whose job descriptions focus on clinical care and either teaching or clinical investigation are likely to be promoted on the basis of CPA, while those whose job descriptions focus predominantly on research are generally promoted on the basis of traditional research criteria (as shown in Table 1). Thus, promotion has been based largely on the platform that is most consistent with the specific job description, thereby providing evidence that the department’s career pathway structure is coherent and internally consistent.
The Challenges and Value of CPA
The main challenge in using the CPA criterion has been the difficulty in providing faculty with a clear description of what qualifies as CPA and effective instruction about how to document it adequately. Just like any other record, the documentation must be maintained prospectively by the faculty member, rather than attempting to assemble a CPA dossier just before seeking promotion. This challenge has required ongoing faculty development both for new faculty members and for their career mentors. In fact, the department recommends that individuals seeking promotion based on CPA review their documentation with a faculty member with prior experience in this matter.
Additionally challenging is the task facing the promotions committee in obtaining appropriate reviews from national or international leaders who understand the nature of CPA. Although the department provides reviewers with the description of the three promotions criteria, many reviewers lack familiarity with the concept of CPA, and instead focus their remarks on the candidate’s research contributions, or lack thereof. This challenge has not been solved, but hopefully will diminish with time as CPA comes into more wide-spread use as a basis for promotion.
Despite these challenges, faculty members in our school’s department of medicine have appreciated the development of the CPA criterion, as it allows greater flexibility in measuring the impact of their academic work while maintaining the high standards of promotion. Other medical schools have also expanded their definitions of scholarship and created new academic job descriptions or promotion pathways in order to reward the breadth of academic activities of their faculty members.9–11 CPA allows our institution to recognize a variety of types of creative work and to reward it through academic promotion, which is one of the highest honors the institution can bestow. We believe that the CPA criterion, as described herein, is consistent with our goals of achieving excellence through original research, education, or creative work that advances the care of patients.
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