Medical schools are facing a number of challenges, including their greater reliance on clinical revenue, increasing competition for research funding, and the need to reform medical education. Each of these challenges has required their faculty to increase their specialization, not only in medical content areas but also in the broader missions of research, education, and patient care. Most schools have responded by recruiting faculty dedicated primarily to the patient care and education missions,1 and these clinician–educator faculty are often vulnerable in traditional systems of faculty reward and recognition.2
A number of institutions have attempted innovative promotion systems for faculty on academic career paths3,4 with variable success in improving the recognition of clinician–educators.5,6 By 2001, 91 North American medical schools had faculty tracks in which clinical and teaching activities were the primary criteria for promotion,7 although many of these were not tenure eligible. Many approaches, such as the recently suggested relative value units for education activities, have not been adequately evaluated to understand their impact on faculty careers.8
The Johns Hopkins University School of Medicine (JHUSOM) has examined its promotion system multiple times during the past decade and each time reaffirmed the premise that the single-track system best serves the needs of its faculty. Three reasons for not developing multiple tracks or specific criteria for promotion may be: (1) a multiple-track system develops elitism within the faculty; (2) tracking faculty limits the opportunities for individual careers to evolve over time; and (3) specific criteria actually constrain the ability of promotion committees to recognize creative and innovative scholarship. The paucity of valid evaluation methods for teaching and clinical practice was also thought to decrease the rigor of the promotion process.9,10 As a result, the school's published promotion guidelines continue to emphasize scholarly publication and national and international reputation as the basis for promotion.11
A 1985 study of the promotion process at JHUSOM found no differences in success of promotion for clinical and research faculty12 and similar numbers of publications in the two groups. The study emphasized that most decisions about faculty tenure were made by the time the faculty members reached age 45. We doubted that clinical faculty were able to maintain such publication productivity in the current climate of accountability in clinical practice and questioned whether the earlier study's findings remain valid. Discussions in our community have suggested that if clinical faculty have not been promoted at similar rates as research faculty, it is because the clinical paths are newer to the institution and populated by faculty who may be less committed to scholarship because of age, gender, or family responsibilities. The purpose of our study was to identify Department of Medicine faculty residing in different career paths and explore characteristics that may differentiate faculty in these career paths, their global work satisfaction, and potential obstacles to scholarly productivity.
We began developing the questionnaire using a nominal group of departmental faculty representing several divisions who worked with previously published definitions to write mutually exclusive descriptors for four career paths.13,14 The “basic researcher” career track was defined as those spending more than 50% of work time engaged in basic science research and having more than 50% of salary supported through extramural grants. The remainder of a basic researcher's time could be spent engaged in patient care, teaching, and administrative activities. “Clinical researchers” were defined as being engaged in clinical research for more than 50% of their time and having more than 50% of their salary supported through extramural grants. Less than 50% of their effort was engaged in direct patient care and as much as 10% could be devoted to administrative or teaching duties. “Academic clinicians” devoted 70% to 90% of their time to patient care with teaching activities occupying the remainder. The “teacher–clinician” pathway was defined as those spending less than 50% of their time engaged in patient care with the remainder devoted to educational administration and teaching. Based on these definitions, faculty were asked to identify the single-best descriptor of their career path.
Nine job satisfaction items were drawn from other published surveys of physicians’ job satisfaction as well as suggestions from the working group.15–17 Other items requested demographic information. Faculty were asked to select categories for years on faculty, rank, years at rank, years at previous rank, hours worked per week, and shared family responsibility. The questionnaire (available from the authors upon request) was pretested for clarity by 12 faculty. After development, the questionnaire was mailed in 1999 to all full-time MD faculty in the department at the rank of instructor and above (268). The questionnaires were coded for confidentiality and tracking. Nonresponders received a second mailing and a final phone call and mailing. Demographic data for the entire department of medicine and JHUSOM were obtained from the faculty management systems maintained by the dean of the School of Medicine.
We used the chi-square test to compare the demographic characteristics of respondents and nonrespondents and assess bivariate associations between categorical items. We used the Kruskal-Wallis test to investigate differences in Likert-scale items by career path. We constructed a global satisfaction score by averaging the possible responses to the nine satisfaction items and used a nonparametric test for trend to assess correlations between it and items ranking likelihood and importance of remaining at JHUSOM.
We used ordinal logistic regression methods18 using the proportional odds model to assess the relationship between academic rank and career path while preserving the ordinal nature of the four level-outcome of academic rank. The coefficients from the proportional odds model provided the log odds of being at a higher rank versus a lesser rank, as a function of predictor variables. We added the covariates of age, gender, years at rank and global satisfaction score to the model. We performed a separate ordinal logistic regression analysis to investigate the relationship between ordered four-level satisfaction with progress in career goals toward academic promotion and career path.
Of the 268 faculty surveyed, nine faculty had left the institution. Of the 259 faculty remaining, 180 responded (response rate = 69%). Two faculty declined to identify a career path, so comparisons by career path are based on 178 responding faculty. We found no significant differences between 79 nonresponders and 180 responders by gender, age, or rank. Table 1 shows the responders’ characteristics compared with faculty of the entire department and school of medicine. There were no statistically significant differences in age or gender by career path.
Workload and Family Responsibility
The proportion of academic clinicians working more than 60 hours per week was greater than for other career paths (see Table 2). Open-ended responses indicated that academic clinicians averaged 1.4 months of general medicine attending per year and 2.5 months of subspecialty attending; teacher–clinicians averaged 1.5 months of general medicine and 2.1 month of subspecialty attending. Career paths did not differ by marital status, number of children, or shared family responsibility. Eighty-five percent of respondents were married, 11% were single, and 4% divorced or separated. Thirty-seven percent of all responding faculty acknowledged 30% or less of shared family responsibility with spouse, and 16% reported handling 60% or more of shared family responsibility.
Men reported working more hours per week than women faculty, but hours worked per week did not differ for men by career path (see Table 3). Women faculty in different career paths, however, reported different hours worked per week. Fifty-seven percent of women academic clinicians reported working 60 or more hours per week. Although more women than men reported higher levels of family burden, the level of family burden did not differ within each gender by career path.
The summary satisfaction score of the nine work-satisfaction items as a measure of “global work satisfaction” showed no difference in global satisfaction by career path. The global satisfaction score was correlated with the following questions: (1) How likely are you to remain at JHUSOM in the next five years? (2) How important is it for you to remain at JHUSOM in the next five years? (3) Have you considered other positions in the past 12 months? Tests for trend revealed significant (p < .001) positive correlations between satisfaction and responses to Questions 1 and 2. Considering other positions was negatively correlated with satisfaction.
Rank and Progress in Promotion
Overall, years as faculty member, years at rank, or years at previous rank did not differ by career path (data not shown). Table 4 shows the results of an ordinal logistic regression analysis in which the odds of being at higher rank were quantified for three of the career paths (clinician researcher, academic clinician, and teacher–clinician) using the basic researcher path as a comparison group and adjusting for the main effects of age, gender, years at rank, and global satisfaction score. We also investigated age–gender interactions, but found they were not influential and, hence, did not include them in this final model. Compared with basic research faculty, the adjusted odds of being at a higher rank were 85% lower for academic clinicians [odds ratio (OR), .15; 95% confidence interval (CI), .06–.40] and 69% lower for teacher–clinicians (OR, .31; 95% CI, .11–.88).
Age and gender were also significant (p < .05) independent predictors of a higher academic rank, but the effect of age was greater than was that of gender. Men were almost three times more likely to be at higher rank were than women, even after adjusting for other factors in the model (adjusted OR, 2.76; 95% CI, 1.24–6.13). A higher global satisfaction score increased the odds of being at higher rank (adjusted OR, 1.97; 95% CI, 1.05–3.68). In contrast, years at rank did not significantly influence the odds of being at higher rank, after adjusting for career path, age, gender, and global satisfaction score. The likelihood ratio test for the baseline model containing only the independent covariates for career path supported the assumption of proportional odds across the outcome categories of rank (6.04 with six degrees of freedom; p = .42).
Table 4 also shows the results of an ordinal logistic regression analysis using the four levels of satisfaction with progress in promotion goals as the outcome with career path, age, gender, years at rank, and global satisfaction score in the model. In comparison with basic researchers, the adjusted odds of being satisfied with promotion progress were 61% lower in clinical researchers (adjusted OR, .39; 95% CI, .17–.89). Similarly, the odds of satisfaction were 92% less for academic clinicians (adjusted OR, .08; 95% CI, .03 = .23), and 87% less for teacher–clinicians (adjusted OR, .13; 95% CI, .04–.42). In this model, age, gender, and years at rank were not statistically significantly associated with satisfaction with promotion. However, a higher global satisfaction score was significantly associated with increased satisfaction with promotion progress (adjusted OR, 69.0; 95% CI, 26.95–176.88).
To our knowledge, this is the first report of a survey comparing faculty satisfaction and rank across career paths within one institution. Sixty-four faculty members, or 35% of respondents, identified with one of the two clinician–educator paths in this department.
Although there was some belief that academic advancement was less successful for these clinical faculty, this had not been previously quantified in our system, presumably because there are no formal career tracks that facilitated this analysis. This survey did not attempt to develop a full explanatory model for slower promotion in these paths, and the questionnaire did not collect information on publication records or incoming rank. We found a dramatic difference in academic advancement between self-reported career paths, however, despite adjustments for age and gender. This result differs from a previously published analysis of promotion success in this institution.12 Some of this difference may be explained by the differences in methodology used. In the previous analysis, faculty who had been placed into the promotion process were compared with those who had left the institution. A troubling concern is whether clinical faculty are now more likely to remain in the institution but are stagnating in the lower ranks.
This is not the first study to suggest a slower rate of promotion for clinician–educator faculty. Kelley and Stross14 found that defined tracks and criteria still result in slower rates of promotion for clinician–educators. This observation suggests that delayed promotion is not an institutional effect but inherent in the career path, which requires time for identification and development of expertise in either clinical or educational fields and time to transition to scholarly efforts from the usual job demands of clinical practice and teaching. An institutional response to this finding would be to identify other standards for advancement in the early years of faculty appointment as a clinician–educator. Our finding of significant differences in satisfaction with progress in career goals suggests that faculty are well aware of their slower progress and that the current single-track system has not eliminated a sense of elitism. The potential consequences of failing to retain clinician–educators in midlevel and senior positions at academic medical centers have been well-described by others.19
We did not find disproportional representations of women in the clinical paths or differences in hours worked or family burdens that would explain potential outside influences on scholarly productivity. Other barriers to promotion may exist, however, that are more amenable to interventions. Studies of women faculty may be helpful models in understanding these barriers. A multiinstitutional study of women faculty reporting low satisfaction with career progress found that women had less institutional support (e.g., research funding and secretarial support).20 Another study noted that women faculty assigned a lower value than men did to leadership and national recognition; women faculty had the least time for scholarly activity and the poorest understanding of promotion criteria.21 Similar themes have appeared in studies of clinician–educators. For instance, one study found that physician–faculty who spent the majority of their time in clinical activities had less time, mentoring, and resources for an academic career.22 So-called protected time is often lost in the busy work week of clinical faculty. Sheffield et al.23 found that clinician–educators spent significantly less time on scholarly activities than is designated for this work. Each of these differences is a potential opportunity for institutional intervention.
A major limitation of our study was its focus on one clinical department within one institution. Although our respondents did not differ from nonrespondents demographically, the results may have been affected by response bias. Satisfied and successful faculty may have felt less inclined to complete the questionnaire. The questionnaire was developed from some items for which reliability was not tested, but most items came from well-validated, previously published instruments. The reliability of the career path definitions has not been tested. The use of the nominal group helped to validate this section of the questionnaire, however, and the consistency of our findings with other studies showing a relationship between satisfaction and intention to leave the institution15,19 supports our belief in the content validity of the items.
We did not collect data on two factors that may have significantly influenced the rate of promotion. First, a faculty member's initial rank at appointment can impact the rate at which he rises through the ranks. Such appointment decisions (e.g., instructor or assistant professor) are usually the discretion of the division chief. We found that 29% of academic clinicians who responded were at the instructor rank, versus 9% of basic researchers and 7% of clinical researchers, which suggests that academic clinicians are more likely to receive lower initial appointments than research faculty or reside at an entry level for a longer period. Second, we did not attempt to measure the scholarly productivity of faculty. Without the ability to assess impact and quality, the working group felt that numbers of publications would be an inappropriate surrogate measure of scholarship, especially for those in the academic clinician and teacher–clinician paths. We felt inclusion of other forms of scholarship24 was also inappropriate because JHUSOM has not formally recognized these forms of scholarship in its promotion guidelines. In a system without explicit criteria, the measure of scholarship is continually evolving. Our goal was to clarify the outcomes of this process.
The department of medicine is the largest department at JHUSOM, and its faculty demographics reflect that of the faculty of the school at large. The challenges clinical faculty face in this department reflect those faced at other institutions, and we feel our findings could be generalized especially to other single-track systems. These results add to the literature supporting the magnitude of the disparity in reward and recognition of clinical faculty. Further research should continue to explore those mutable predictors of career advancement and interventions that will diminish this disparity. Our discussions have suggested potential interventions at several levels, including improved orientation of faculty to the promotion process, mentorship and faculty development that encourages scholarly activities such as collaboration and dissemination of work, institutional criteria for promotion specific to the career path of the clinician–educator, and representation of senior clinician–educators in the evaluation of faculty work and promotion process. Each of these interventions should be explored and evaluated for their impact on faculty satisfaction, promotion, and retention.
The authors wish to acknowledge the work of other members of the Clinician Educator Task Force, especially Rita Falcone, MD, and Emma Stokes, PhD, in the initial work of survey design, and Drs. Michael Klag and David Levine for reviewing earlier drafts of this manuscript.
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