The changing academic medical environment of the past decade has prompted a redefinition of faculty roles nationwide. The traditional “triple-threat” faculty member who has the time to participate fully and achieve excellence in research, clinical care, and teaching is becoming less possible or practical. Increasingly, faculty have a primary role in one of these missions. In addition, the economic necessity of generating income through clinical care to subsidize teaching and research activities has led to a rise in the number of faculty members who are designated as clinician–educators or clinician–investigators. In some schools, these different faculty roles are defined within distinct faculty series or tracks with specific criteria for academic advancement and promotion. The number of medical schools with clinical tracks increased from 61 in 1986 to 91 in 1998.1,2
The University of California (UC) defines five distinctive academic series (tracks) for medical school faculty that differ based on role and responsibility within each of the university's missions (research, education, clinical care, and community service), Academic Senate membership, support by state funds, and opportunity for tenure. These five series are intended to provide faculty with an appropriate context for their professional activities, and, ideally, should improve faculty's opportunities for academic success since advancement within each series is judged by series-specific criteria. However, these series remain controversial. Both faculty and their department chairs often question the necessity and effectiveness of these series, debate their appropriate use, and claim that they create a caste system in which some faculty are perceived as more valuable or important than others. In this report, we describe the five faculty series within the UC system and their differing application at the five UC medical schools. We also present merit and promotion outcomes and trends for faculty within these series at one of these medical schools.
Table 1 summarizes key features of the five faculty series within the UC system, as defined in the University's Academic Personnel Manual.3 These series chiefly differ on sources of salary support, tenure eligibility, expectations for clinical service, and membership in the Academic Senate. Privileges associated with the latter include voting in university-wide and school-wide Senate activities and membership is granted to all faculty members in the appropriate series. Departmental voting privileges are not necessarily tied to Academic Senate membership and vary based on departmental bylaws.
Three series are considered to have a primary focus on hypothesis-based research: the Ladder-Rank, In-Residence, and Adjunct series. The Ladder-Rank series is the original faculty series and the only one in which faculty are both tenure eligible and receive state funds for salary support. The number of positions in this series is based on enrollment and is therefore limited and fixed. Additional faculty members have been increasingly necessary to meet the schools’ missions, and therefore other series have been added over the years. Other series that also focus on hypothesis-based research include the In-Residence series, which usually is supported by income from clinical practice in addition to grants, and the Adjunct series for nonclinical scientists who are primarily grant supported. Both of these series were added in the early 1960s. Two additional series emphasize the clinical care role and have been added over the past two decades: Clinical X, a series for clinician–investigators and educators added in the early 1980s; and Salaried Clinical, a series for clinician–educators added in the early 1990s. As shown in Table 1, the criteria for research in the Clinical X series are very broad. Although the types of research described in other series are not excluded, creative work that would not be considered appropriate in the research-intensive series, such as book chapters, reviews, case series, and educational products, are suitable for the Clinical X series. Other than the established criteria for appointment and advancement for each series in the UC Academic Personnel Manual, there are no written guidelines regarding appointing a faculty member into one series versus another, and chairs typically appoint a faculty member into the series that best fit the faculty member's interests and the department's needs. Although there are no restrictions or recommendations as to the appropriate proportion of faculty in each series on the department or school level, the university does limit the number of Clinical X faculty members to one sixth (16.6%) of the Academic Senate membership, as described in the UC Academic Personnel Manual. Exception to this rule requires permission of the campus chancellor.
The University of California Merit and Promotion Process
Faculty in all academic series at the UC undergo merit reviews at regular intervals in each rank within a series. Merit advancement is denoted by a step advancement within that rank and is associated with an increase in the base salary. The base salary is that component of the salary determined by academic rank and step which is the same for all faculty members at that level in the university. There are four usual steps at the assistant professor rank, three at the associate professor rank, and nine at the rank of professor. Medical school faculty receive additional salary based on productivity and other negotiated factors. Merit reviews occur every two years for assistant and associate professors, and every three years for professors. Merit reviews are conducted in turn by the department, dean, and the School Personnel Committee (SPC). The SPC is composed only of faculty from the School of Medicine. The University of California, Irvine, is the only school in which all faculty undergo merit review by the campus-wide Committee for Academic Personnel (CAP) rather than the SPC. CAP includes one or two members from the School of Medicine, but is composed chiefly of faculty from other schools within the university. CAP performs promotion reviews for Academic Senate members and high-level merit advancements for professors advancing to Step VI at all of the schools on campus.
Faculty members in all series are required to apply for promotion from assistant to associate professor within seven years of their appointment. All faculty members (except for those in the Salaried Clinical series) who are not promoted are not retained by the university. A formal appraisal of a faculty member's accomplishments by the various levels of review to assess his or her prospects for promotion occurs in year four of the assistant professorship. At this time, faculty members are encouraged to assess, with the advice of their chairs, whether they are in the academic series most appropriate for their interests, talents, and the departments’ needs, and whether to change series at this time. Changing series is usually not permitted when submitting a promotion dossier or following an unsuccessful promotion application.
During the 2001–02 academic year, one of us (KDB) conducted an in-person interview or a phone interview lasting 30 minutes to an hour with the associate dean for academic affairs at each of the five UC medical schools. In these interviews, KDB used a focused approach with a set of structured, open-ended questions to elicit information and comments on the following topics: the number of faculty in each of the academic series (excluding the Adjunct series), the role of the different series, and any problem areas associated with them. The five UC medical schools are University of California, Davis (UCDavis), School of Medicine; University of California, Irvine (UCI), College of Medicine; University of California, Los Angeles (UCLA), David Geffen School of Medicine; University of California, San Diego (UCSD), School of Medicine; and University of California, San Francisco (UCSF), School of Medicine.
We obtained academic merit and promotion results for one medical school (UCDavis) from the school's Office of Academic Affairs for three consecutive academic years (1999–2000, 2000–01, and 2001–02). The merit and promotion results are averaged for this three-year period. The data reported include the percentage of faculty within each series whose merit or promotion action was approved, denied, or modified. A modified action is defined as a final result that was different from that originally requested. Examples include accelerated advancement of a faculty member to a higher academic step than requested (i.e., an associate professor Step I advanced to associate professor Step III rather than Step II) or advancement to a higher step within the faculty member's current rank in lieu of the requested promotion (i.e., associate professor Step III advanced to associate professor Step IV rather than professor Step I).
Comparison of Faculty Series within the University of California Medical Schools
Table 2 shows the number of faculty in each faculty series (excluding the Adjunct series), and the percentage of faculty in each series who were members of the academic senate in 2001–02 at each UC medical school. Data in Table 2 are from KDB's interview with each associate dean for academic affairs. All deans defined the Ladder-Rank and In-Residence series as those in which faculty devote much of their time to hypothesis-driven research that explores areas such as basic science, social science, educational scholarship, and translational or clinically oriented work. At UCDavis, the average Ladder-Rank faculty member spends more than 50% of his or her time in research, although this can vary by department.
The series with the most variability among the UC medical schools was the Clinical X series. The percentage of the university-wide Academic Senate members who were Clinical X faculty was 39% at UCDavis, 20% at both UCSF and UCSD, 12% at UCLA, and 8% at UCI. Only UCDavis significantly exceeded the one-sixth (16.6%) Academic Senate membership cap for Clinical X faculty described in the UC Academic Personnel Manual. As noted previously, exception to this rule requires permission of the Chancellor. All UC campuses agree on the general criteria that faculty within this series must participate in applied or translational clinical investigation or investigation in educational scholarship, and that faculty must make significant contributions to the knowledge or practice in their field that are disseminated outside the institution, usually through publication.
UCLA, however, rarely appoints faculty to the Clinical X series until promotion to the associate professor level, since they reserve this series for faculty who have distinguished themselves as master clinicians or master teachers. The majority of clinically oriented faculty at this institution begin their careers in the Salaried Clinical series. This is seen as a strategy to improve promotion success. All the campuses agree that there are no publication requirements for advancement in the Salaried Clinical series, although they do expect members of this series to support the clinical research program of others, such as identifying patients for clinical studies. UCLA is unique in that it appoints all of the physicians practicing in their primary care network into the Salaried Clinical series since the university uses the primary care network as teaching and clinical research sites. As a result, they have a large number of faculty within this series and expect their Salaried Clinical physicians to provide collaborative input into clinical research and teaching programs. They have even developed a journal in which their primary care network physicians can publish their contributions.
Other campuses do not extensively use their primary care network as major sites for educational or research purposes, and therefore do not appoint physicians who practice in this network into the Salaried Clinical series. Instead they use the nonacademic Managerial and Professional Series. Nonetheless, Managerial and Professional Series physicians are assigned the title of volunteer clinical faculty, which is the identical title (clinical professor) given to Salaried Clinical faculty. Some campuses, such as UCSF, report that faculty in the Salaried Clinical series feel like “second-class citizens” as a result of this issue.
Merit and Promotion Results for Academic Series at the University of California, Davis, School of Medicine
For the academic years 1999–2000, 2000–01, and 2001–02, the average number of faculty in the UCDavis, School of Medicine seeking promotion to each rank per year was 17 to the rank of professor, and 19 to the rank of associate professor. Within each series, the average number of faculty members seeking promotion each year consisted of eight in the Ladder-Rank, eight in the In-Residence, four in the Adjunct, 11 in the Clinical X, and six in the Salaried Clinical. Because of these small numbers, it is not possible to evaluate yearly trends. Therefore, the promotion results are averaged for all three academic years and shown as percentages in Figure 1. Likewise, the results from merit advancements are also averaged for the same academic years and are shown as percentages in Figure 2. The average number of faculty seeking merit advancement in each series per year were 51 in the Ladder-Rank, 17 in the In-Residence, 13 in the Adjunct, 41 in the Clinical X, and 23 in the Salaried Clinical.
There are three type of results from a merit or promotion action: approval, denial, or a modified action. Figures 1 and 2 illustrate that merits and promotions had similar rates of approvals, denials, or modified actions across the series, indicating that the different committees reviewing merits and promotions were consistent in their application of criteria. Other than the Ladder-Rank, all series had an approval rate greater than 90% for promotions. Regarding approval of merit advancements within the assistant, associate and full professor ranks, only the Ladder-Rank and In-Residence series were less than 90%. Faculty in the Salaried Clinical series had the highest approval rate for both merits and promotions. Faculty in the Ladder-Rank series had the highest denial rate for promotions, and were tied with faculty in the In-Residence series for the highest denial rate for merit actions. The denials in the Ladder-Rank and In-Residence merit actions chiefly consisted of senior faculty seeking advancement to the uppermost levels of the professorial ranks. A “plateauing” phenomenon is not uncommon for faculty at this level. Modified results are minimal in number for both merits and promotions, but have actually been noted to be increasing over the three-year period we studied. Before this time, modified results were rare or nonexistent, and there were more denials for both merits and promotions across the series. The recent increase in modified results represents equity review efforts, and approximately one third of all modified promotions results indicated an accelerated advancement to a step higher than that requested. We noted a similar phenomenon for the merit actions.
Table 3 shows the final results for promotion and upper-level merit actions for the UCDavis, School of Medicine and other large colleges and schools within the university for 2001–02. The percentage of denials for the School of Medicine was midrange of the percentages of denials in other schools on the UCDavis campus.
An increased emphasis on the clinical enterprise to support medical schools’ academic mission has prompted a diversification in the composition of faculty and their distribution within tenure versus nontenure tracks. In recent years, medical schools have greatly increased the number of faculty whose primary responsibility is the clinical mission. To accommodate these faculty within the academic environment and to facilitate their evaluation within the existing merit and promotion process, many schools have created “clinical tracks” that are typically nontenured. The number of faculty within these clinical tracks is growing at a rate that has outpaced the growth of tenure-track faculty. In addition, new faculty members with chiefly clinical roles are being appointed into nontenure tracks, rather than the earlier practice of appointment into tenure tracks. During 1981–83, an Association of American Medical Colleges survey indicated that 68% of all clinical faculty were in tenure tracks versus 46% in 1997–99. A few schools have limited tenure-eligibility to basic science faculty.4
As Barchi and Lowery5 point out, these changing definitions of medical school faculty, the faculty's growing size and influence compared to other schools in their parent university, and their different perspective on scholarship and academic values can lead to tension in the medical school's relationship to the university community as a whole. Clinical medical school faculty tend to have different values, definitions of scholarship, and teaching roles, and often identify more with the medical center than the general campus. These feelings can be exacerbated by physical separation and limited opportunities for interaction with faculty members in other disciplines. At UCDavis, almost 40% of the university's Academic Senate is composed of nontenured medical school faculty. To limit the influence of the clinical faculty, most of the UC medical schools follow the rule in the Academic Personnel Manual that the clinical faculty cannot exceed one sixth of the membership of the Academic Senate. Only UCDavis greatly exceeds this cap.
As clinical tracks are created and implemented, one area of contention between medical schools and their parent university is the criteria for promotion and advancement. As is the case at many medical schools, there is oversight and scrutiny at UCDavis by a centralized campus committee, the Committee for Academic Personnel, and the vice provost of academic personnel in an effort to maintain academic standards. Even at medical schools with more independence in promotion and advancement decisions, their affiliation with the parent university still requires the maintenance of certain general standards. Medical school faculty frequently feel that they are disadvantaged in the review process since they believe that the faculty in other parts of the university don't understand or appreciate their accomplishments. At some schools, such as the University of Michigan, Harvard University, and the University of Kentucky, these issues have prompted redefinition of the clinical tracks and clarification of the criteria for promotion and advancement. This has served to educate the clinical faculty as to what is required for success in their track, and to educate their tenure-track colleagues, particularly those outside the medical school, about the definition of scholarship within the clinical disciplines.6–8 Similarly, at UCDavis in 2002, the Academic Senate formed a committee that wrote a clarification of the criteria for promotion and advancement in the Clinical X series to expand the generic description in the Academic Personnel Manual. The UCDavis Committee for Academic Personnel has followed with a request for all departments throughout the university to create a document describing their respective criteria for scholarship, so that the university can judge faculty members appropriately and within the context of their own fields when considering requests for promotion. Such efforts are not universally recognized as laudatory or advantageous. Our experience at UCDavis, however, like that of others, indicates that the majority of junior faculty feel that they otherwise get inconsistent advice and that more specific guidelines and criteria facilitate their opportunities for success.7
Despite the common forces prompting the creation of clinical tracks both nationally in the United States and in California, the academic series designated as clinical tracks in the UC system (Clinical X and Salaried Clinical series) are used differently at the five UC medical schools. UCDavis has been appointing junior faculty directly into the Clinical X series. This has had mixed results since departments haven't always had the resources to sustain sufficient protected time for development of the faculty member's clinical research or educational program. When a faculty member has not made adequate progress by appraisal time (midway through the assistant professor years), she or he has either had to move to the Salaried Clinical series, which was not the type of career originally intended, or the faculty member has had to “work against the clock” to meet promotion requirements. These faculty have felt disappointed and somewhat misled.
As Levinson and Rubinstein9 describe, an approach typical of many academic medical centers is the use of clinician–educators as short-term employees since they are unlikely to meet the university's criteria for promotion. However, this has a markedly negative effect on morale and does not develop faculty with experience and expertise. Levinson and Rubinstein encourage academic medical centers to cultivate a long-term cadre of clinician–educators and clinician–investigators. The strategy of several of the UC medical schools of differentially appointing junior faculty into the Salaried Clinical series offers an opportunity to develop this cadre of expertise. Initial appointment in the Salaried Clinical series may offer a safe starting place for faculty members to establish themselves as a clinical-investigator or clinician–educator without the pressure of the seven-year academic clock for promotion. Those who distinguish themselves as excellent can then transfer to the Clinical X series where the merit and promotion criteria include scholarly achievements that recognize the broader definition of scholarship appropriate to clinical faculty. This group then becomes the cadre of long-term clinician–educators or clinician–investigators who provide the experience and continuity for ongoing development in education or clinical research. Although this strategy has not been as common at UCDavis as it has been at our sister schools, it is being increasingly acknowledged as advantageous, used by a growing number of chairs, and encouraged by the dean. However, it must be noted that an initial appointment in the Salaried Clinical series can only fulfill its role as a “safe starting place” for junior faculty members if it includes a commitment by the department for protected time, mentoring for scholarly development despite the nonresearch orientation of this particular series. This commitment of protected time has been problematic in the Clinical X series, and prompted the new and controversial requirement for 20% protected time in the new guidelines for appointment and advancement in that series. Chairs increasingly recognize that a commitment of appropriate support is a worthwhile investment that results in more productive, successful, and long-term faculty.
The variety of academic series or tracks in the University of California system does appear to successfully describe faculty jobs and provide distinctive measures for merit and promotion. As the experience at UCDavis illustrates, medical school faculty are successful in the merit and promotion process. This can be seen in the similar rates of success for merits and promotions across the different faculty series within the School of Medicine, and the School of Medicine's overall success rate for promotions compared to that of other UCDavis schools. The high merit and promotion approval rates for the clinical tracks (Clinical X and Salaried Clinical), which meet or surpass some of the research tracks, indicate that the accomplishments of the clinical faculty are increasingly understood, valued, and rewarded.
Shifting from a predominance of tenure-track appointments to an increasing number of nontenure track appointments has a varied and often subtle impact. All of the UC medical schools reported that feelings of inequity and “second-class” citizenship continue to exist among faculty in certain series because of differences in state support, Academic Senate membership, perceived job security, and work assignments. Members of the tenure-track series are still preferred as high-level leaders in the medical school, even though many faculty in non–Ladder-Rank series serve in important roles. This is seen as a mechanism of protecting the academic missions and culture of the school, since it is assumed (perhaps wrongly) that faculty in nontenure track series don't equally value research and teaching. It is this assumption that underlies the limit on Academic Senate membership of nontenure track faculty, but is perceived by many as elitist and inaccurate. Concerns about academic freedom can also exist when the majority of the faculty are untenured. Fortunately, the UC's Faculty Code of Conduct addresses issues of academic freedom and is applied to all faculty, regardless of academic series.10
It is essential that the leadership of medical schools continue to acknowledge that a diverse complement of faculty roles is essential in achieving their missions, and that the contributions of all faculty are valuable and should continue to be rewarded through the merit and promotion process. The well-accepted concepts of diversity that medical schools commonly draw on regarding ethnicity, race, and gender to enrich their faculty, student body, and programs need to include diversity of academic tracks so that there is an appropriate and effective mix of interests and talents to meet the missions of the school. Incorporation of these values into the fabric and culture of a school is vital to the successful implementation of clinical faculty tracks. Finding that appropriate mix and proportion of faculty within different faculty tracks, however, cannot be left to chance if faculty tracks are to be maximally effective. Medical schools need to consider what constitutes the optimal composition of their faculty. This represents a current focus at the UCDavis, School of Medicine.
The authors wish to acknowledge the following deans for their assistance during interviews addressing faculty series and practices at their medical schools: Thomas Anders, MD, former executive associate dean, School of Medicine, UCDavis; Dennis D. Cunningham, MD, senior associate dean for academic affairs, College of Medicine, UCI; William F. Friedman, MD, senior associate dean for academic affairs, David Geffen School of Medicine, UCLA; Jerry A. Schneider, MD, dean for academic affairs, School of Medicine, UCSD; Neal H. Cohen, MD, dean for academic affairs, UCSF.