Bunton, Sarah A. PhD; Mallon, William T. EdD
For three decades, studies have examined the nature of faculty appointment, tenure, and promotion policies in U.S. medical schools.1–8 Reviewed longitudinally, these reports reveal two prominent reasons for the continued evolution of faculty appointment policies: (1) to respond to the uncertainties of the financial model in which medical schools operate, and (2) to acknowledge the different needs, responsibilities, and expectations of various faculty members.
For many years an incongruity existed between the tenuousness of U.S. medical schools’ financing and the stability of institutional commitments to faculty. As others have described, medical schools have operated with a financial model of uncertainty and volatility.9 In contrast, medical faculty employment arrangements typically modeled the stability and security of policies promoted by the American Association of University Professors, in which tenure was designed to protect academic freedom and bring “a sufficient degree of economic security to make the profession attractive to men and women of ability.”10 For many years, tenure typically was thought to guarantee the full salary of medical faculty, and the ability of a medical school to reduce salaries or eliminate positions was considered to be extremely constrained. Over time, however, medical schools have been forced to align their faculty employment policies and practices with the economic realities of their environments.
Changes in faculty work responsibilities and preferences have also contributed to the continued evolution in faculty appointment and tenure policies. The difficulty of establishing research careers in an era of increased competition for grants and greater work pressures to fulfill patient care responsibilities has prompted a reconsideration of probationary period length; expanding definitions of scholarship have led to new faculty promotion pathways; and the changing composition of the faculty itself has prompted institutional flexibility. For example, the proportion of female medical school faculty members has continually increased,11 and a younger generation of both male and female faculty has demanded policies that accommodate a more balanced work and family life.12–13
In this article, we present data from 2005 that extend the aforementioned themes. We describe tenure systems, trends in the number and percentage of full-time faculty on tenure-eligible tracks, the financial guarantee of tenure, and probationary periods for both clinical and basic science faculty in U.S medical schools. We then briefly review the status of flexible policies, including clock-stopping policies, part-time tenure options, and track choices. Finally, we highlight two current faculty policy changes that many institutions have made or are actively contemplating: the recognition of interdisciplinary and team science and a broadening view of scholarship.
The data in this article come primarily from responses to the 2005 Faculty Personnel Policies Survey, a survey conducted by the Association of American Medical Colleges (AAMC) of the 125 U.S. medical schools accredited by the Liaison Committee of Medical Education. Administered triennially since 1994, the survey instrument consists of questions about policies and procedures related to appointment, promotion, tenure, and compensation structures for medical school faculty. Deans or designated staff members with expertise in an institution’s policies governing faculty appointment, tenure, and compensation completed the survey instrument, which received a 100% overall response rate. We supplemented survey responses with data from the AAMC Faculty Roster database— a national database that tracks characteristics of more than 95% of all full-time U.S. medical school faculty—and from institutional policy documents, bylaws, and faculty handbooks.
Prevalence of Tenure Systems and the Tenure Track
As previously reported, tenure systems remain well established in U.S. medical schools.1,3,5,6 In 2005, only six of the 125 U.S. medical schools did not offer tenure: Boston University School of Medicine, Mayo Medical School, Morehouse School of Medicine, Ponce School of Medicine, Universidad Central del Caribe School of Medicine, and Wright State University School of Medicine. Six additional schools generally limit tenure eligibility to basic science faculty: Brown Medical School, Loma Linda University School of Medicine, Northeastern Ohio Universities College of Medicine, Tufts University School of Medicine, University of Missouri–Kansas City School of Medicine, and Sanford School of Medicine of the University of South Dakota.* Except for the inclusion of the University of South Dakota, this list has remained unchanged since the last comprehensive report published in 1997.6
Although tenure systems remain common, the proportion of faculty on tenured or tenure-eligible tracks has changed significantly over time, especially for clinical faculty. In 1985, 57% of full-time MD faculty in clinical departments were either tenured or on the tenure track, but in 2004, this percentage decreased to 42% (Figure 1, top panel). Yet, an important, and sometimes overlooked, component of this analysis is that the number of tenured and tenure-eligible MD clinical faculty increased by 50% during the same period: from 14,026 in 1985 to 21,921 in 2004 (Figure 1, bottom panel). In other words, there were far more, not fewer, tenured and tenure-track clinical faculty at U.S. medical schools in 2005 than ever before. Yet, the percentage of tenure-eligible clinical faculty declined even while the absolute numbers increased, because the number of nontenure-track clinical MDs grew even faster: from 8,612 in 1985 to 27,207 in 2004 (an increase of over 315%). During these two decades, as medical schools expanded their clinical enterprises, they most commonly populated their faculty ranks with nontenure-track MD practitioners whose primary responsibility was patient care.6 In the period from 1985 to 1995, although tenured and tenure-track clinical MDs increased at an average rate of 4% per year, they were still eclipsed by nontenure-track MDs, which realized a sizable growth rate of 8% per year (Figure 2). From 1996 to 2002, the growth in tenure-eligible clinical MD faculty decreased to an average rate of 1% per year.
Although the steady decline in the overall percentage of tenure-eligible MD clinical faculty is certainly noteworthy, it would be difficult to conclude that tenure is in jeopardy of disappearing for these faculty, at least in absolute terms. New MD faculty in clinical departments, however, are increasingly appointed to nontenure-eligible positions, thus influencing the overall trends in tenure status. In 1985, 41% of newly hired full-time clinical MD faculty were on tenure-eligible tracks, but in 2004, that percentage declined to 28% (Figure 3).
As previously reported,8 there has also been an increased use of nontenure-eligible appointments for basic scientists during the past two decades, although the change is much less dramatic than for clinical MD faculty. In 1985, 83% of PhD basic science faculty were either tenured or on the tenure track; in 2004, this percentage had declined to 76% (Figure 4). During this time, the overall number of PhD basic science faculty steadily increased from 8,726 in 1985 to 12,553 in 2005. Unlike the trends for clinical faculty, the patterns of tenure status for basic science faculty are consistent with those for all faculty in higher education: 78% of all full-time faculty at four-year U.S. colleges and universities were tenured or on the tenure track in fall 2003.14 Despite the decrease in tenure-eligible appointments, the majority of basic science PhD faculty continue to have traditional academic appointments.
Although tenured positions in both basic science and clinical departments serve as mechanisms to attract and retain exceptional faculty by providing stability and security, they remain more common in basic science departments for several reasons: first, the growth in the biomedical research enterprise in medical schools notwithstanding, basic science departments have not realized the same levels of explosive growth in faculty positions as have clinical departments. Second, basic scientists’ salaries, on average, are far lower than their clinical counterparts. To the extent that the push for nontenure-track appointments is rooted in institutional fear of having to support full salaries regardless of the productivity of individual tenured faculty members, that fear would be much greater with highly paid clinical subspecialists than with basic science bench researchers. Finally, we assert that the culture in basic science departments, on average, is more akin to the traditional academic ethos in other university divisions than to the health care–driven environments of clinical departments. In other words, it is our supposition that basic science faculty have held onto the notion that tenure matters to a greater extent than have clinical faculty.
Similar to the pattern seen for clinical MD faculty, a large part of the decreasing percentage of tenure-eligible positions for PhD basic scientists is driven by new faculty hires. For newly hired full-time PhD basic science faculty, 68% were on tenure-eligible tracks in 1985 compared with 51% in 2004 (Figure 5). Previous research has suggested that medical schools have increased the use of nontenure tracks, as they have hired more junior research faculty whose positions are funded completely on grant funds to afford flexibility in terminating such appointments if that grant money ends.8
Relationship between Tenure and Guaranteed Salary
Historically, tenure has been linked to the economic security of faculty members.10 The modern concept of tenure, however, especially for medical school faculty, does not necessarily encompass this concept.15 Of the 113 medical schools that offered tenure to clinical faculty in 2005, 56 (50%) had a financial guarantee associated with tenure, whereas 43 (38%) had none (Table 1). Of those 56 schools with a tenure guarantee, only three asserted that they guaranteed total institutional salary, and all three were considering a revision or clarification of what portion of compensation was guaranteed by tenure. The majority of institutions with a specific tenure financial guarantee for clinical faculty defined the guarantee as base salary, whether it was the state-funded portion of salary or was otherwise defined. Similar patterns exist with basic science faculty. Of the 119 medical schools that offer tenure to basic science faculty, 62 (52%) noted that tenure had a specific financial guarantee, and 42 (35%) had no financial guarantee associated with tenure. Of those with a tenure guarantee for basic scientists, only eight schools (13%) guaranteed total institutional salary.
These relationships continue to change: 12 schools (10%) revised or clarified their tenure guarantee policies between 2002 and 2005, and another 17 schools (14%) were actively considering such changes in 2005. Medical schools also continued to resolve unclear policies in this area: the percentage of schools indicating that their tenure financial guarantee for basic science faculty was not clearly defined declined from 20% in 20028 to 10% in 2005.
The changes in the financial guarantee associated with tenure during the last several decades have transformed the fundamental concept of tenure at many medical schools. At more than 40 institutions where tenure does not guarantee any level of salary support, the meaning of tenure is no longer clear. Does tenure protect job security or academic freedom if a tenured faculty member’s salary could effectively be reduced to zero? Many medical schools may have reached the point at which the difference between tenured and nontenured faculty appointments is more symbolic than substantive, more important for prestige than for job protection.
It also seems that enough medical schools have altered tenure policies that academic medicine has reached a tipping point in the fundamental faculty reward structure. Historically, that structure guaranteed job security and stability and protected time for scholarly pursuits in exchange for lower salaries than those found in industry and other sectors. Limited financial remuneration was not as important as the benefits of tenure and other intrinsic rewards.16 That traditional reward structure for a majority of faculty in academic medicine is now an anachronism, replaced with a contract—implicit or explicit—that aligns risk with reward, where guaranteed salary through tenure has been diminished or has vanished, and contingency-based (i.e., bonus and incentive) pay structures are common, certainly for clinical faculty and now, too, for basic science faculty. As a case in point, in 2004, 78% of medical school clinical faculty and 59% percent of basic science faculty were eligible for bonus pay, and 52% of clinical faculty and 20% of basic science faculty received bonus pay (AAMC Faculty Salary Survey, unpublished data, 2005).
Flexibility in Tenure Policies
To meet the needs of medical school faculty who are facing increased pressures to develop research agendas, attract funding, fulfill patient care responsibilities, contribute to the educational mission, and balance work and family demands, institutional policies increasingly permit flexibility for tenure-track faculty. These strategies include lengthening the pretenure probationary period, offering clock-stopping policies, and creating new appointment tracks.
The percentage of medical schools that have lengthened the probationary period for tenure-track faculty beyond the traditional six- to seven-year period endorsed by the American Association of University Professors (AAUP) has steadily increased since 1983 (Table 2). In that year, of those medical schools with fixed probationary length, 74% (70/95) had probationary periods of seven or fewer years for their clinical faculty; by 2005, 57% (61/107) of schools did. Similar trends exist for basic science faculty: in 1983, 74% of schools (73/99) had probationary periods of seven or fewer years for basic science faculty; in 2005, 61% (69/114) of schools did. Many of these changes have occurred recently: 10 schools (8%) noted that they lengthened their pretenure probationary period for basic science faculty between 2002 and 2005, and another 11 (9%) were actively considering a change in 2005. Eleven schools (9%) made a change in probationary period length for clinical faculty between 2002 and 2005, and another nine (7%) were actively considering a change in 2005. These policy revisions typically reflect the difficulty for faculty to become established within the traditional time frame because of increasing demands on their time as they also try to maintain a balance of work and family.17
Tenure clock-stopping and part-time tenure policies.
Another institutional strategy that purports to offer flexibility to tenure-track faculty is tenure-clock-stopping policies. These policies, which allow faculty on a tenure-eligible track to extend the probationary period, were available at 82 (69%) medical schools in 2005. These policies could be used for child care (at 87% [71/82] of the institutions with such policies), care for sick family members (84% [69/82]), and for a medical disability (84% [69/82]), among other reasons. Yet, critics have noted that these policies fail to offer flexibility for tenure-track faculty because they are rarely used.18–19 Our data support this point. Of the 82 medical schools with tenure-clock-stopping policies in 2005, 57 were able to provide recent statistics about the use of these policies by their faculty members. At these 57 institutions, an average of only 1.0 men and 1.5 women at each institution used these policies each year in 2003–2004 and 2004–2005.
Medical schools and research universities continue to wrestle with how to translate flexible policies into practice. As our data indicate, few medical school faculty actually use policies to extend probationary periods. Innovative ideas taken from the higher education sector are, therefore, now being considered. In 2005, for example, Princeton University began to automatically grant an extra probationary year to all faculty with a new child rather than making faculty members specifically request the extension.20 The purpose of the automatic extension was to remove the stigma associated with the request. Medical schools might consider similar policy revisions to increase the use of such flexible policies.
Some institutions also have policies that allow faculty to work less than full-time while remaining on a tenure-eligible track. Such policies were available at 37 (31%) medical schools offering tenure in 2005. Here, too, a disconnect exists between having policies on the books and faculty members’ use of the policies. Of the 37 medical schools with part- time tenure policies, 23 were able to provide recent data on the number of tenure-track faculty who worked less than full-time. At these institutions, an average of 4.1 men and 4.3 women at each institution used the policy each year in 2003–2004 and 2004–2005.
New faculty tracks.
During the past 25 years, medical schools have introduced various faculty appointment tracks or pathways to accommodate the differing work arrangements of clinical and research faculty. These types of policy changes have continued in the last few years. Twenty-seven institutions (22%) reported that they introduced a new faculty track or career pathway between 2002 and 2005. Many of these new tracks are based on well-established models. For example, several schools instituted nontenure-eligible research tracks for faculty who are affiliated with independent research centers or programs or who are engaged in research support activities but do little teaching. The Feinberg School of Medicine at Northwestern University created its research track to “[permit] appointment of scholars to the faculty on a nontenure basis in order to participate in and cooperate with the research efforts of faculty with tenure-track appointments.” For clinical faculty, clinical educator tracks have frequently been added for faculty who are engaged primarily in patient care. The University of Virginia School of Medicine created a tenure-eligible track for faculty who spend approximately 80% of their time “devoted to patient care and/or teaching [and] 20% of time devoted to scholarly activities with research focused in the area of medical education.”
A different type of faculty track has also emerged recently. The University of Iowa Carver College of Medicine, University of New Mexico School of Medicine, East Tennessee State University Quillen College of Medicine, and West Virginia University School of Medicine have introduced an “undeclared,” or “flex,” track for new faculty, in which faculty do not have to choose a tenure-eligible or nontenure track at the initial point of their hiring. This option has been designed for several reasons. In some cases, the parent university has not permitted the medical school to extend the traditional probationary period. An undeclared track effectively accomplishes that goal. Also, this type of track is designed to give basic science faculty time to garner R-01 grants as well as clinical faculty time to establish their clinical practice before turning to research. Officials at the University of New Mexico, for example, report that most clinicians without previous research training opt for a nontenure-track clinical educator track if forced to choose on initial appointment. With the undeclared track, however, clinicians can establish a clinical practice and then focus more attention after 2 to 3 years to developing a research program. Without the pressure to address all parts of their career at the same time, a greater number of clinicians, they hope, will ultimately choose a tenure track (Susan Scott, MD, senior associate dean for academic affairs, University of New Mexico School of Medicine, written communication, October 2005).
Emerging Tenure Policies
Two trends in promotion and tenure policies have emerged in the last few years as particularly important at large numbers of U.S. medical schools, and we anticipate these issues to continue to be at the forefront of policy discussions in upcoming years: first, institutional recognition of interdisciplinary and team science in the tenure and promotion process, and second, the evolving notions of educational scholarship.
Emphasis on interdisciplinary team science
Many medical schools recently have incorporated or are discussing the recognition of interdisciplinary team science in the tenure and promotion process. Historically, medical schools have emphasized individual faculty work in their structure, through promotion and tenure guidelines, and in their culture. As biomedical research increasingly becomes interdisciplinary, however, scientific process often demands collaboration with teams of researchers from diverse fields, creating a difficult situation for some faculty—they may wish to engage in interdisciplinary research, but their institutional policies and practices serve as roadblocks for the recognition of such work in the promotion and tenure process.
Some medical schools have begun to modify their policies to address the need for greater collaborative and team-based research. Between 2002 and 2005, 15 medical schools (12%) revised their tenure and promotion guidelines to include an emphasis on interdisciplinary team science, and another 24 (19%) were actively considering such a change. For example, Vanderbilt University School of Medicine has included recognition of collaboration in its criteria for promotion and tenure; at the time this article was written, the language had not been added to its promotion and tenure guidelines, but it had received endorsement of the executive faculty:
Vanderbilt recognizes the critical importance of collaboration (“team science”) in research and scholarly activity and that the contributions of middle authors in multiauthored publications are often seminal and of the highest quality. When the research and/or scholarship is pursued in a collaborative fashion and results in multiauthored publications, the specific contributions of the candidate must be clear and significant. The candidate’s role can be described via the Critical Reference Form that must be included in the promotion dossier. In addition, the Chair, the manuscript’s senior author, and external correspondents can make an assessment of the quality and impact of a middle author’s contribution. (Steven Gabbe, MD, dean, Vanderbilt University School of Medicine, written communication, June 2006.)
Michigan State University College of Human Medicine also has incorporated the notion of collaborative work in their definition of scholarly activity contained in their promotion and tenure guidelines:
To advance in rank in any of the faculty appointment systems, all MSU-CHM faculty members should regularly communicate newly obtained and/or applied knowledge and analytical thinking to their peers both within and outside the university. Accordingly, generating high-quality, peer-reviewed publications (e.g., journal articles, electronic publications, other scholarly works) based on original research by faculty members, including research conducted in collaboration with colleagues, students, and postdoctoral associates, represents a major source of evidence for productive research activity [emphasis added].21
Not all schools have gone so far as to specifically include new policy language in promotion and tenure documents. At one school, for example, the dean made an announcement about including translational research in the consideration of scholarship at the 2004 state of the school address. Yet, without codifying such pronouncements into formal policy, their effectiveness may be unclear, especially as administrators and tenure and promotion committee members come and go. Rewarding the collaborative contributions of faculty is an integral component of an organizational milieu that supports interdisciplinary work. Turning rhetoric into policy and practice is essential to facilitate collaborative and team-based science. As basic research and clinical application require greater links among and beyond disciplines and across institutions, institutions will need to interweave these realities into the fabric of promotion and tenure.
Expanded definition of scholarship
Another revision to appointment, promotion, and tenure policies is the incorporation of an expanded definition of scholarship. Scholarly activity has been a prominent component of medical schools’ tripartite mission of clinical care, education, and research. Traditionally, recognition of scholarship has focused on the conventional areas of hypothesis-driven research or clinical application. In the last decade, the academic medicine community, as well as higher education more broadly, has debated the notion of educational scholarship, its role in career advancement, and evidence of its achievement for purposes of academic recognition and reward.22
Medical schools are engaging in these discussions because of the rapid growth in the number of clinical faculty with heavy patient care responsibilities who have a difficult time meeting promotion criteria that reward a traditional notion of scholarship.23 Broadening these definitions to include other types of scholarly activities acknowledges the various career structures and pathways at the modern medical school. Although discussions about this matter have occurred during the past several decades, it has only been recently that medical schools have incorporated different forms of scholarship into their promotion and tenure guidelines. For example, at the University of Michigan Medical School, the criteria for promotion on the instructional track states:
All Instructional Track faculty must be individuals of scholarly ability and achievement. Scholarship may be categorized in terms of the scholarship of discovery (basic research), scholarship of integration, scholarship of application, and scholarship of education. Interdisciplinary work, success in training graduate and professional students (as attested to by academic/research positions obtained), participation and leadership in professional associations, and editing of professional journals are measures of success and stature in scholarship. Peer-reviewed papers and grant funding are strong evidence of scholarship with high impact. Independent and peer-reviewed funding is the norm in research-based careers. There should be a strong prediction of continued excellence throughout the faculty member’s professional career.24
Similarly, the University of Kansas Medical Center recently added a clinical scholar track for faculty “whose primary mission is education with a component of their position to include the scholarship of education, learning, or discovery and/or service.” Other institutions such as Case Western Reserve University School of Medicine, the University of Washington School of Medicine, and Mercer University School of Medicine are working to include revised advancement criteria for various faculty pathways, including the evaluation of clinical care or teaching for promotion and tenure.
The Continuing Evolution of Faculty Policies
For the last 30 years, financial uncertainty, changes in health care delivery and reimbursement, and changing workforce needs have prompted medical schools to depart from faculty employment norms that were developed in a different era and to continually refine their appointment and tenure policies. Given the predictions about the new generation of faculty members,19 we would expect to see continued growth of flexible policies such as probationary period extensions, track changes, and flexible career pathways.
An institutional environment and culture that support the use of flexible policies are also important in encouraging a match between academic structure and faculty career needs. Yet, our data also suggest that having policies in place is not necessarily sufficient to address the issues for which they were created. The fact that, on average, fewer than three men and women per medical school used clock-stopping policies from 2003 to 2005, and the low number of faculty that used policies to work less than full time while remaining on a tenure-eligible track, indicates a dissonance between policy and practice. Although some faculty choose not to use these policies out of a desire to move through the faculty ranks at a normative rate, others may not take advantage of the flexible policies because of constraints of the clinical and research workplace, an institutional culture that discourages their use, or their ignorance that such policies exist. Each barrier must be removed.
The ultimate goal of faculty appointment and tenure policies, of course, is to structure career pathways that accommodate the needs and preferences of both the medical school and its faculty to ensure academic quality, attractive and rewarding work environments, and sustainable institutions. Thirty years ago, Spellman and Meiklejohn1 predicted the “continuing modification and experimentation” of faculty policies “to promote equity, retain the effectiveness of faculty members, assure access to the academic ladder for young persons and members of minority groups and women, and at the same time enable appropriate institutional responses to financial problems.” We suspect this will still hold true 30 years from now.
The authors acknowledge Robert F. Jones, PhD, Diane Magrane, MD, and two anonymous reviewers for insightful feedback on earlier drafts of this manuscript; the many medical school deans, faculty affairs deans, and other medical school officials who generously contributed their time to describe school policies; Hershel Alexander, PhD, and Yolanda Vogel for providing Faculty Roster data; and Wendy Desmarais for providing AAMC Faculty Salary Survey data.