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Defining Scholarship at the Uniformed Services University of the Health Sciences School of Medicine

A Study in Cultures

Marks, Eric S., MD

SPECIAL THEME: Expanding the View of Scholarship: CASE STUDIES
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Medical schools' long-awaited recognition of the varied contributions of their faculty has caused active dialogue and debate. The discourse centers on the best approach for incorporating a broader definition of scholarship, including professional service, into the traditional promotion and tenure processes. At the School of Medicine of the Uniformed Services University of the Health Sciences (USUHS), the majority of the clinical faculty also serve as active-duty uniformed medical officers, and the subject of how to appropriately recognize their varied contributions has long been contended. Concerns have been raised from all constituent groups that broadening the definition of scholarship at the USUHS has the potential to lower the standards of the academy and thus devalue faculty positions. The USUHS has viewed this challenge as a study in the integration of cultures. Institutional cultures include those of the academy, the military, government, basic science, and clinical science, and all the resulting permutations. A nine-year review of scholarship, promotion, and tenure at the USUHS has resulted in a document that supports the diverse missions of the university and appropriately rewards the accomplishments of its faculty. The dialogue continues, as the new document is subject to continuing review and ongoing critical analysis.

Dr. Marks is associate professor, Department of Medicine, and associate dean for faculty affairs, the Uniformed Services University of the Health Sciences, Bethesda, Maryland.

Correspondence and requests for reprints should be addressed to Dr. Marks, Associate Dean for Faculty Affairs, 4301 Jones Bridge Road, Bethesda, MD 20814-4799; e-mail: 〈emarks@usuhs.mil〉.

The opinions expressed in this paper are solely those of the author and do not necessarily reflect the opinions of the Department of Defense, the Uniformed Services University of the Health Sciences, or other federal agencies.

The ongoing transition in the definition of scholarship and its application within the Uniformed Services University of the Health Sciences School of Medicine (USUHS) began in 1991 and is first and foremost a study in the influence of culture. Cultures in our institution include those of the academy, the military, government, basic science, clinical science, and all the resulting permutations. The interface between the military and academic communities catalyzed a redefinition of scholarship at the USUHS.

The USUHS was established in 1972 with a clearly defined mission to train uniformed medical officers. A uniformed medical officer simultaneously serves two professions: the medical profession and the military profession. The preponderance of USUHS students enters one of the three military services, with a small number serving in the Public Health Service. Similarly, the vast majority (>95%) of our clinical faculty are active-duty military medical officers. As such, they occupy a unique position within American medicine. They serve in the traditional roles of practitioners but in addition have a multitude of other responsibilities unique to the uniformed community. They are called upon to design and adapt health care delivery systems and provide care in a number of different environments, from shipboard to jungle, from conflict to humanitarian missions, and in the traditional hospital and clinic settings. As a part of their normal responsibilities they serve as educators at the undergraduate and graduate levels while participating in “operational medicine” activities and providing health care to the various communities they serve. In these varying roles and positions, our faculty accomplish substantial work that in the past was viewed as simply “service,” or work that was “just part of the job,” much in the same way that teaching has traditionally been considered a task that comes with the position of academic physician but that is not a “true” area of scholarship. The concept that these activities of USUHS faculty were somehow “scholarly” was neither widely nor strongly supported. In reassessing these activities in an expanded context of scholarship, the university was forced to consider what our values really were and how our support and reward systems reflected these values.

The dissatisfaction on the part of our clinical faculty in terms of recognition was most clearly manifested in complaints about our academic titles. Initially, in the original Appointment, Promotion and Tenure Instruction (implemented in 1981), our clinical faculty were classified as “volunteers,” similar to the local private-practice clinical faculty who support teaching activities in most academic medical centers. In addition, the School of Medicine modified academic titles, predominately in the clinical departments. For example, both “clinical professor of…” and “professor of clinical…” titles were applied, and they served to differentiate faculty in terms of both time committed to university educational activities and the extent of research productivity. Although the university provided guidelines, departments were not consistent in how they applied them, and this led to increasing difficulty when faculty were evaluated for promotion. The Committee on Appointment, Promotion, and Tenure (CAPT) would routinely reject promotion proposals for clinical faculty that involved the use of an unmodified title. In retrospect, promotion criteria for all faculty were relatively inflexible, with “research and teaching” accomplishments considered to be the primary, if not the sole, basis for promotion. Essentially there was no clear definition of scholarship. This resulted in limited numbers of promotions for the clinical faculty and lent credence to the general consensus among this group that their role in the mission of the School of Medicine was not appreciated. The issue of modified titles was the most frequently quoted example of a “town vs gown” mentality.

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RE-EXAMINING THE PROMOTION AND TENURE PROCESSES

In our first attempt to rework the appointment and promotion process we abandoned the volunteer classification as a clear acknowledgement of the intrinsic importance of our clinical faculty to the teaching and professional role-modeling missions of the school by our clinical faculty. Following three years of proposals, review, and debate, in 1994 a new Appointment, Promotion, and Tenure Instruction provided additional guidance and criteria for assessing scholarly accomplishment and established a clinician-educator pathway within the tenure-ineligible track (federal policy prevents our uniformed faculty, as they are active-duty service members, from being in the tenure track; however, they are entitled to the same level of academic due process as their civilian colleagues). It was apparent soon after the Instruction was issued and implemented that it did not successfully define scholarship or what scholarly “value” was to be placed on the broad range of faculty activities. It also did not address the frequently expressed concerns and frustrations of junior faculty within the basic science departments, who were directed to be highly competitive in research while simultaneously assigned substantial teaching responsibilities. Teaching was seen as not being appropriately rewarded, and this commonly-held opinion precluded some faculty from pursuing interests in the educational process. It was primarily for these reasons that we undertook a complete re-evaluation of what we would consider a scholarly accomplishment and the appropriate institutional recognition for such scholarship. A key element that allowed the School of Medicine to pursue this objective was the selection of a new dean who was dedicated to addressing these issues and moving the process forward. It was during this period of time that the office of associate dean for faculty affairs was established to coordinate and facilitate this and related faculty initiatives.

Early in the process, we were influenced by Boyer's definitions of the scholarship of discovery, integration, teaching, and application.1 The division of scholarship into these four categories was meant not to separate them but simply to allow each to be examined in terms of its components. The criteria we have embraced for a scholarly accomplishment are designed to be applied universally without regard to the forum in which the activity occurs or its subject. Acceptance of that principle allows for a breakdown of the boundaries imposed by an individual's membership within a particular culture. We hold that we have a faculty composed of individuals who perform scholarly acts. It is only through a shared understanding and acceptance of what defines such acts that our faculty can move toward becoming a collegial community of scholars.

The defining elements of scholarship were determined to be innovation, originality, creativity, and peer recognition, including dissemination, acceptance, and impact. These attributes could be examined in the context of the work presented for review. For example, in recognition that much of the written materials that are prepared in federal service do not necessarily carry the name of the author but rather attribute the material to the institution, agency, or group, it was necessary to investigate the concept of “publication equivalents.” These disseminated materials had to meet the stringent criteria established for work published in the more familiar “peer-reviewed journal.” The criterion of true peer recognition and review, in association with the necessity for dissemination, was considered to be essential. For our purpose, the peers of the faculty candidate are the community of scholars and professionals in the discipline, field of study, or activity of which the candidate is a member of participant. This provides the range of input necessary from the various groups represented by our faculty, but it requires that we seek to enlarge the faculty community's knowledge of the range of activities in which its members are engaged. This knowledge is essential if the accomplishments of each faculty member are to be appropriately appreciated and weighted.

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IMPLEMENTING BOYER'S MODEL

After a five-year series of discussions and various modifications and revisions, a faculty consensus was reached and the following definitions were accepted as policy for the school of medicine. The scholarship of discovery was defined as original, disciplined research that expands or challenges current knowledge. It encompasses the pursuit of phenomena and observations, which results in the generation of new knowledge. The knowledge provided by the scholarship of discovery is assimilated and interpreted through the scholarship of integration and is shared through the scholarship of teaching and of application.

The scholarship of integration combines and connects various disciplines through the process of creative synthesis or analysis and seeks to interpret, draw together, and bring new insight to bear on original research. It provides meaning to isolated facts, and illuminates data by putting them in perspective and fitting them into larger intellectual patterns. It requires innovative thinking that integrates knowledge from various fields, bringing different perspectives to bear on central themes.

The scholarship of teaching communicates understanding. It challenges, extends, and transforms the knowledge of discovery into something students can comprehend. The scholarly enterprise of teaching includes the creative development of innovative pedagogic practices and course materials, and aims to encourage independent learning and critical thinking. Scholarly teaching requires enthusiastic, intellectually engaged faculty who are well informed about the latest advances in their disciplines.

The scholarship of application refers to the responsible implementation of knowledge gained from the other three forms of scholarship. Application is a scholarly engagement with society, building bridges between theory and practice by applying knowledge to practical problems. It encompasses professional service, including clinical activities. The activity of application is dynamically related to the other kinds of scholarship; it is directly tied to one's special field of knowledge and can itself give rise to new intellectual understandings.

Most faculty clearly understand the meanings of the scholarship of discovery and the scholarship of integration, as their primary focus is research. On our campus interdisciplinary programs in neuroscience, molecular biology, and emerging infectious diseases provide working examples of discovery combined with integration. It is the incorporation of other faculty accomplishments into the remaining areas of scholarship that continues to be the greatest challenge. Many faculty have voiced the belief that teaching and application (professional service) are not as rigorous in their academic demands. As a result, some faculty believe that including these areas in the promotion process will allow some individuals who are not productive in the laboratory to attain academic ranks that in the past were reserved for the successful researcher who also taught. This has challenged us to carefully examine how we will apply our criteria and conduct our evaluations. We have attempted to make it crystal clear that our renewed emphasis on recognizing the scholarly components of teaching is in no way a repudiation of the importance of the scholarship of discovery and its research foundation. The criteria for promotion for an individual whose primary focus is in teaching and educational research requires the same attention to detail and critical analysis expected in other areas of research. We continue to strive to establish a system that will accurately assess the quality of the various components of teaching, including students' performance and the teacher's contributions to peers.

We evaluate professional service activities, including clinical activities, on the basis of the professional expertise required and the extent of peer recognition. As such, many of these activities are considered evidence of the scholarship of application. In the area of service, both the community served and the level of discipline-specific expertise required were determined to be the main criteria for differentiating between professional service (a peer-recognition activity with scholarly components) and institutional citizenship (the reasonable responsibility of any faculty or institutional member). This division allowed the use of the criteria for the scholarship of application (and, in some cases, of the scholarship of teaching) to be applied to these areas of faculty activity. Professional service to the uniformed services or other federal departments and agencies, and involvement in professional, educational, scientific, or community organizations at the local, state, national, or international level are considered by the CAPT and evaluated for their scholarly value.

The evaluation of the scholarly components of clinical activities, including the innovative and thoughtful application of knowledge and experience, serves as a good example of the use of our expanded definition of scholarship. We contend that an additional component in this educational setting is the teaching by example of the personal characteristics of honesty, compassion, dedication to patient welfare, and sensitivity to the human aspects of medical care. These attributes as documented by peer evaluation are considered an essential component in appointment and promotion reviews of health care professionals who deliver patient care and teach in the clinical environment. The USUHS recognizes that the transmission of clinical knowledge, skills, and professional attitudes requires that the clinical teacher have an ongoing involvement in patient care to assure that the teaching is relevant to actual practice. Expertise in this area also requires that the clinical teacher keep abreast of advances in relevant basic science and be able to communicate this new knowledge to students and explain its relevance to the clinical setting.

An excellent example of the type of activity that combines different areas of scholarship in a nontraditional academic environment was a recent “operational medicine” exercise. To provide a realistic training experience for the crew and medical staff of a U.S. Navy hospital ship intended for humanitarian missions, a number of our faculty wrote a series of clinical scenarios, trained a cadre of simulated patients, developed pre- and post-exercise criteria for the evaluation of crew and patient performances, developed instruments to obtain input from practitioners and patients, and, after evaluating the data, provided an educational report. The results were provided to the command authority, shared with participating medical personnel, and maintained to serve as a basis for additional educational research activities within the School of Medicine. Here were integration, application, and teaching in a real-world environment. The information learned from this experience continues to benefit the general community; in addition, since many members of the ship's medical staff are faculty members, the lessions they learned will in turn benefit our students and other faculty. This activity was not simply service or “line of duty” work—it meets all our criteria for scholarly work.

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ESTABLISHING NEW PROMOTION AND REWARD CRITERIA

It was clear from the outset that to reassure faculty whose academic careers had been dictated by the “traditional” system of requirements, accomplishments, and rewards, it was essential to establish a clear definition of a “scholarly work” based on defensible criteria. A recurrently voiced fear is that any redefinition of the “traditional” criteria will serve to lower our academic standards and thus reflect poorly on the USUHS and its faculty. This opinion continues to be the major impediment to universal faculty acceptance of the ongoing evolution—or, as some of our faculty see it, the ongoing revolution—in the definition of scholarship. This response is not unique to our campus, and its historical basis is well described by Rice in his working paper, Making a Place for the New American Scholar.2 The task for the promoters of cultural change is to somehow facilitate openness to new ideas and concepts—the same type of openness that allows for the free exchange and critical analysis of ideas that is the foundation of academic thought and processes. (This task was brilliantly captured in a cartoon characterization of the famous Sir Isaac Newton apple legend. In the drawing, a world globe is shown falling from a tree and striking a smiling human figure on the head; the caption reads “Open your mind and say Ah.”)

Using the new definitions and criteria, a diverse faculty committee examined the common types of faculty accomplishments that could be considered by the CAPT. From that review, a non-exhaustive list of examples was generated to guide faculty candidates, department chairs, and the CAPT. Once these new criteria were generally accepted, a reassessment of the academic title system became the main priority. It was decided that the “clinical” modifier would be removed from use. To accomplish this without losing the basic rationale for its existence, and to prevent a reduction in the level of accomplishment required for each academic rank, a new clinician-investigator pathway was developed and the promotion criteria for the clinician-educator pathway were enhanced. However, many were reluctant to accept this change. Criticism came not only from the basic science constituency but also from clinicians who had invested a significant portion of their careers in bench and clinical research and who saw the removal of the “clinical” modifier as a move to diminish the value of their titles. It is interesting that some faculty appeared to believe that they would be judged outside our institution mainly on the basis of the academic titles they attained rather than on the accomplishments that earned the titles. Our institution, and I assume all others, evaluate candidates based on what they bring to the desired position. How will they meet the mission and expectations of the USUHS? Our new criteria of scholarship encourage our current and prospective faculty members to bring all their cards to the table and be judged accordingly. It was discussed and acknowledged that some faculty who would have been promoted within a modified titling system will now remain for longer, if not indefinite, periods at the assistant professor level. However, the basic intent throughout the process has been to maintain high academic standards while giving serious consideration to the amount of time and effort each faculty member spends in university-related activities.

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A WORK IN PROGRESS

Educating our faculty about the meaning of our definitions of scholarship and their implementation continues to be of the highest priority. We have undertaken a major effort to visit clinical sites, meet with departments, provide information via our Web-based faculty handbook, and offer consultation to faculty and chairs alike. The initial implementation stage uncovered a number of issues that have emphasized that this is a “work in progress.” Issues and questions continue to be raised as we deal with both the substance and the interpretation of the changes. Examples of these concerns included the absolute value of external funding and its source as criteria for promotion, criteria for the evaluation of teaching contributions, and the various manifestations of peer recognition. Our response has included some minor revisions to the documents and, more important, the development of a comprehensive plan to study the various components of teaching and its evaluation.

The commitment of the university and the School of Medicine to not asking a faculty member to do something without providing the means for accomplishing the task has led to a new appreciation of the need for professional development. We see professional development as a broader concept than faculty development. Individuals are more prone to accept the advantage of “development” programs if they see them as opportunities to enhance their personal professional growth and not simply as additional tasks. The programs we anticipate creating will be based on combining the professional aspirations of our faculty with the missions of our university. This is a direct result of our broadening of the definitions of scholarship, because these definitions now encompass a range of activities that in the past would have been less valued within the academic arena. To change a behavior and the culture that encourages it requires that clear benefits must be seen. Redesigning titles, mandating criteria, and establishing numerous academic tracks and pathways are not the methods that will encourage persistent movement and growth. Linking the ability of an individual to do what that individual sees as being in his or her best professional interest and the missions of the academy enhances both. Recognition of the variety of scholarly activities further enhances the faculty, for it allows for continual professional growth. Our faculty, like many others, has members that evolve through a series of stages in their careers. Diversity in scholarship allows faculty to undergo the types of changes in interests and motivation that are both natural and essential for individual renewal, professional satisfaction, and productivity. We accept that unexpected events, particularly for our uniformed faculty, may move them throughout their careers into positions that in the traditional academy would not be considered conducive to scholarly work. However, within those positions there are usually opportunities to apply the one or more of the skills that distinguish a scholarly accomplishment. It is our belief that by recognizing these activities we will encourage our faculty to bring back the knowledge and experience they gain and, through the activities of teaching and application, enhance the university community as a whole.

Debate on our campus continues, and old beliefs die slowly and painfully. The faculty assembly through our faculty senate continues to provide a forum to discuss these matters. We encourage ongoing dialogue as a means for enhancing understanding. Involvement in and service to the larger community—the people of the United States—has always been at the foundation of the USUHS mission. We believe that we have developed and implemented a system based on an enhanced appreciation and recognition of scholarship that will better enable us to fulfill that commitment.

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REFERENCES

1. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: Carnegie Foundation for the Advancement of Teaching, 1990.
2. Rice RE. Making a Place for the New American Scholar. New Pathways: Faculty Careers and Employment for the 21st Century. Working Paper Series. Washington, DC: American Association for Higher Education, 1996.
© 2000 Association of American Medical Colleges