Last month, I turned in my 40-page proposal for promotion and tenure. The package includes all my publications, educational portfolios, honors, and awards to sum up my last seven years of employment. I don’t know if I am more relieved or anxious.
When I began in this role, I was charged and enthusiastic, thrilled to be starting my first academic faculty job. My father would have described me, using one of his favorite phrases, as “bright-eyed and bushy-tailed.” I now spend most of my time conducting research on issues related to maternal mental health. I teach residents; see patients in my outpatient clinic; and staff the low-risk labor, delivery, and newborn inpatient service run by our Department of Family Medicine. I find great reward in caring for patients, but the hours of inpatient call can be grueling—700 hours in the hospital last year, day and night, covering our service, all while running up against the tenure deadline.
When I sought a faculty position, I took for granted that I would be on the tenure track. I had four years of fellowship training in research, and the tenure track seemed expected. Tenure has been around since 1940 and was initiated to ensure that faculty cannot be fired without due cause and to guarantee academic freedom.1 It isn’t necessary to have tenure for a fulfilling primary care career; as a family physician I get daily e-mails from recruiters who flood my mailbox with postcards of picturesque landscapes where I could enjoy camping and hiking in the mountains in a “very safe community” just “three hours from a major metropolis.” For clinician–scientists, tenure is still the gold standard at many institutions, but being on the tenure track is less common in primary care, with only about 20% of full-time family medicine faculty being on track for or having tenure among schools which offer tenure.2 For me, this meant a greater sense of responsibility and pressure to get tenure so that I could represent my specialty well.
The fluidity of a research schedule means flexibility, but it also makes it easy to blur work and home boundaries. The tenure countdown does not stop on weekends or holidays. The push to write and publish can feel relentless. Since manuscripts may be rejected from multiple journals before finding a home, getting published requires persistence and having more than one paper at a time under review. Wary of approaching career deadlines, I had a burst of productivity in one summer month and submitted six separate manuscripts to academic journals.
But life still goes on, despite the ticking of the tenure clock.
In a recent October, shortly after my six submissions, I came home from a busy 24 hours on call. I had gotten just 45 minutes of sleep and was bone tired. I felt the relief of turning over my phone and pagers to the next physician and knowing I no longer needed to worry about the laboring patients. I began to relax. But as I was changing out of my scrubs, the phone rang. My father had been ailing for many months. That morning, he was found unresponsive. By 11:30, I was sitting at Gate A28 at the Detroit airport, waiting for my flight. My phone rang again, this time a nurse I had never met, asking permission to bring in hospice care for my father. While I was giving consent, I heard the boarding call for my flight in the background. I walked down the boarding ramp feeling drained and exhausted, placed my luggage overhead, and my phone rang a third time. My father was dead.
These stressful pretenure years typically occur at the same time a faculty member is building a personal and family life, perhaps dating or getting married, maybe starting a family, up at night breastfeeding, or caring for a sick infant or toddler. The “sandwich” generation frequently bears responsibilities not only for caring for young children but also for caring for aging or ill parents. There are child care expenses and medical school loans. All of this is happening with the quiet, but still audible, ticking of the tenure clock in the background.
Around the time my father died, I had several academic disappointments. In the summer before his death, a major grant was returned unscored. In the fall, a second grant was also unscored. While the reviews were fair, it was painful to get two major rejections in a row. The six papers so impressively submitted in a single month were also all rejected in a single month down the road, an unanticipated side effect of efficiency. My National Institutes of Health (NIH) K23 training grant came to an end, and my research coordinator left for a different position because of my lack of funding.
In the same season, I became sick and ended up in the hospital. While there, my grandfather also became ill. Over the next month I closely followed his declining health and then found myself back at the airport gate in Detroit, waiting for another flight to the Midwest. On Christmas morning, six weeks after my father’s death, my grandfather died.
The criteria for awarding tenure differ across universities and across disciplines, with a universal focus on publications, grants, and national reputation. Many universities have expanded the time frame to accommodate leaves of absence for health or family reasons. However, tenure is still described as an “up-or-out” process, and one in five faculty nationally are denied tenure and lose their jobs each year.3 I know several bright and hardworking colleagues who applied for tenure but were denied. Their experiences loomed as an ever-present threat as I approached my own tenure review. These last several years, I have felt I could not stop pushing forward, and I could not slow down, even as I became more overwhelmed by other events in my life.
I was initially told that I needed a funded RO1 (the main, large research grant from NIH) or an equivalent large grant to get tenure. Although I know that all researchers struggle to obtain NIH funding, I began to harbor a secret sense of shame at not having an RO1. I asked for advice from senior mentors in family medicine, but many described a promotion process from a different era, when individuals with no grants and few publications received tenure. A colleague offered this advice: “When I was in your position, people were practically throwing money at me and asking me to write grants so they could give me funding!” Once, I was making a national presentation about my research on physician mental health and was caught off-guard when a faculty member in the audience from another university raised his hand and asked, out of the blue, “Why are you still an assistant professor? I’ve been looking at all your publications in PubMed and you’ve published an amazing amount!” Rarely speechless, I didn’t know how to respond to this. I felt flattered and ashamed at the same time. The years of working toward this goal had taken a substantial toll on my own sense of confidence and well-being.
As the clock moved forward, I sought advice from senior faculty members in family medicine and in other specialties about when to go up for tenure. Their guidance left me no less confused.
Well, you used to need an RO1, but that’s changed with the funding climate.
I tell the junior faculty in our department [a medical specialty] to wait—people try to go up too early and get rejected.
Oh, I’m sure you’ll get tenure—you deserve it! You should definitely go up this year.
You’ve been done a disservice [by those who advised you to go up for tenure]. Tenure represents a ‘contract’ with the university that you will fund your salary.
Well, I know people who don’t have a grant who have gotten tenure and they haven’t published half as much as you have.
You should not go up this year. Others will let you know you need an RO1.
That’s not true, we’ve promoted people without an RO1.
In the end, ironically enough, I had no control over the timing. After months of intense work to submit an RO1 grant application, working nights, weekends, over holidays, and while on call, I started to ease back into a more relaxed schedule, catch my breath, and get caught up on projects that had been pushed aside. Later that month I was informed that my tenure proposal package was due in three weeks. I panicked. For various technical reasons, I did not actually have the choice to wait. So, with or without an RO1, I went back to the long days, the exhaustion, and the relentless anxiety. I wrote up my achievements as best I could, revised compulsively, pressed “send,” and it was done.
Since then, I have experienced an odd feeling of lightness which I have not felt for a long time. As I write this, my RO1 application is under review. I do not know if it will be funded or even scored. It will be another year before I hear the outcome of the tenure review. But knowing it is out of my hands has relieved much of the ever-present pressure I have felt for years. The high levels of internal drive and perfectionism, characteristic of most academic physicians, sync well with the demands for tenure but also increase the risk for setting unachievable expectations. I know that if tenure is denied, I will be looking for a new job. But to be honest, I also understand now that this could not possibly be as bad as how I have felt for the past several years, the stress of tenure punctuating every manuscript, every call, and every clinic. I’m hopeful that the passion I once felt for research will come back; I see glimpses of it now and again. Medicine needs dedicated clinician–scientists who can stand with one foot in clinical medicine and one foot in the research arena; we have a special role in improving patient care through investigation and in mentoring students and residents. Being a clinician–researcher is not easier or harder than seeing patients full-time, but there are different drivers of stress and burnout, and different patterns to our daily lives. And in my own background noise, the tenure clock ticks on.
The author would like to express gratitude to Thomas Schwenk, MD, and Mack Ruffin IV, MD, for reviewing drafts of this essay and offering unwavering support and guidance over the tenure-track years.