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Invited Commentaries

Is Academic Medicine Ready for Term Limits?

Austin, Jared P. MD

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doi: 10.1097/ACM.0000000000003020
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Abstract

Disparities in academic promotion and leadership for women and minorities remain significant problems in academic medical centers (AMCs).1–5 While many articles have addressed the social and cultural barriers to advancement for these groups,6–10 few have focused on the structural frameworks that underpin AMCs and how these structures promulgate disparities in power sharing.11 One such structural issue involves the lack of term limits for those in positions of power, including presidents, provosts, deans, department heads, and committee chairs. In this Invited Commentary, I examine arguments for and against term limits in academic medicine.

Term limits have long been debated in the political arena.12,13 They were initially intended to encourage innovation, limit the power of incumbency, and increase the diversity of elected officials, but studies have shown they have minimal effect.14–16 Specifically, research indicates that the racial and gender composition of legislatures after the institution of term limits in U.S. states with such limits is not significantly different than before—and that, likewise, the racial and gender composition between states with and without term limits does not differ significantly.17,18 Nonetheless, in 2016, shortly after the 115th Congress was sworn into office, and despite broad bipartisan and executive branch support, legislation to institute term limits on national office holders was squashed. Senator Mitch McConnell, the senate majority leader and one of the longest tenured U.S. senators in history, ended debate, remarking, “I would say we have term limits now. They’re called elections.”19 Debate on this subject in the national political scene may have cooled, but since AMCs enjoy no such mechanisms as elections. I believe debate on term limits within academic medicine needs to begin.

Perhaps the most obvious potential advantage of term limits is the ability to encourage innovation by infusing leadership positions with individuals who bring with them fresh, novel ideas and the energy and passion to move those ideas forward.20 AMCs are replete with faculty members who have occupied positions of authority for many years, sometimes decades. Since typically no mechanism short of death or retirement exists to transfer power from the individuals in these leadership positions, the positions themselves have become the equivalent of endowed chairs. In cases where passionate, visionary, and/or transformative leaders occupy these positions, the institution and the faculty benefit. These leaders are rare, however, and sometimes positions are held by individuals who may have initially brought energy, enthusiasm, and novelty to the position, but have since stagnated. They may become, in the words of Bereiter and Scardamalia, “experienced non-experts.”21 Term limits would ensure that positions of power transfer to new leaders more frequently, both limiting the potential for stagnation and increasing the opportunity for innovation. Indeed, some studies from the business world have shown that novel and innovative solutions arise from the turnover created by term limits.20,22 Especially with the recent push toward curricular reform,23,24 this option, as a further driver of innovation, deserves attention.

In 2018, the Association of American Medical Colleges reported that 19% (618/3,274) of department chairs and 18% (27/152) of medical school deans were women even though women constituted 42% of the faculty.25 Additionally, a 2012 study of medical school deans showed, first, that women occupied their positions for significantly less time than men—3 years versus 5 years—and, second, that 0% of women occupied their positions for longer than 9 years, compared with 16% of men.26 Although aggregate data for other positions of leadership (e.g., committee chairs, clerkship directors, and residency program directors) are lacking, similar trends may exist. Term limits could help achieve parity and equality in leadership at all levels by facilitating turnover, which in turn, would provide potential opportunities for women and minorities. Consequently, as more women and minorities achieve positions of power and become visible role models, the barriers associated with imposter syndrome27,28 and stereotype threat,29,30 particularly among early-career individuals, might decrease, and these individuals—and, importantly, people who look like them—may be more likely to pursue positions of power in the future.

Indeed, encouraging more participation of women and minorities in politics was an important driver for the institution of term limits in the 1990s.15 However, in the political realm, term limits have not been shown to increase the percentage of women and minorities elected to office.31 Importantly, however, the differences between politics and academic medicine are substantial, and extrapolating findings and trends from politics to medicine may lead to inaccurate conclusions. At the very least, given the persistent and ongoing disparities in leadership among women and minorities in academic medicine, which could, according to one report, persist for another 50 years,32 instituting term limits seems like a viable option for effecting change.

In addition to the benefits for prospective leaders, term limits may also help current leaders. For example, term limits may allow individuals to exit positions gracefully and predictably, before burnout or stagnation occurs. Outgoing leaders could then pursue other positions or areas of interest, thus broadening and enriching their careers.

Term limits would also benefit AMCs by facilitating transitions from one leader to the next at expected and predictable times, thus reducing the disruption that results from sudden and unexpected departures. Notably, however, studies of term limits in politics have revealed that legislators tend to leave office sooner than term limits would dictate, and the goal of predictable transitions has not been realized.31 One postulated reason for the lack of predictable transitions in politics is that legislators, knowing their terms will eventually expire, tend to pursue higher priority positions when opportunities arise (rather than waiting until their current term ends).33 For example, in California, state house legislators tend to run for (or “graduate” to) state senate positions before their terms in the lower house are up. This tendency has created a rotating system of lawmakers, with both positive and negative effects. A similar cascade could occur in academic medicine; for example, a department head might vacate the position to become a dean and then relinquish the deanship to become a provost or president when the opportunity arises. However, such a scenario is no different from the current situation; those seeking to climb the academic hierarchy already employ a similar strategy. Term limits could serve to expedite this progression, allowing others to pursue vacated positions sooner. Faculty in AMCs where turnover is already frequent might view such institutionalized turnover negatively, but those in AMCs where turnover is infrequent may view the more frequent changes positively. A one-size-fits-all model is unlikely to be successful. Instead, local institutional patterns, needs, and norms will need to be taken into account when designing and implementing term limits.

One of the potential downsides of term limits is the inhibition of the development of expertise. Individuals who have retained positions for long periods of time may develop deep knowledge in their areas of authority. In education, for example, a long-serving clerkship director may have refined the curriculum and assessment methods used in her clerkship over years, garnered leadership positions within national organizations, and conducted scholarship within a niche area of clinical learning. A department chair who has served for many years may have creatively managed the budget during times of relatively low and high revenue, providing stability for faculty. Individuals such as these who have held positions of power for prolonged periods of time may leverage their accumulated institutional memory to make more informed decisions, but such institutional memory may be difficult to pass along to new leaders.34 Term limits could harm institutions by forcing these knowledgeable, experienced individuals from their specialized roles.

Of additional concern, studies in politics have suggested that in U.S. states with term limits, power may shift away from legislators and toward long-term staffers, lobbyists, and/or governors.35 While reducing the power of incumbency is a goal of term limits, shifting this power to unelected individuals and separate branches of government is not. Providing adequate overlap between incoming and outgoing leaders, as well as encouraging mentorship between the two, could potentially mitigate these unintended and undesirable effects. Indeed, in politics, both early mentorship by senior lawmakers of junior members and early incorporation of new lawmakers into committee chairmanships and other leadership positions have mitigated the power of staffers and other branches of government.31 In medicine, the creation of additional leadership positions, such as those of assistant or associate deans, could provide consistency and continuity and ensure that leadership power remains within the control of academic leaders.

Another potential downside to term limits is the possibility of frequent leadership turnover, which can be destabilizing to an institution, department, or residency program. Indeed, some have viewed the retention of individuals in leadership positions for long periods of time as attractive.36,37 For example, on an institutional or departmental level, large capital projects may require many years to plan, finance, and complete. Turnover in the midst of a project may be detrimental to its completion. Two means of mitigating frequent or untimely disruptions include ensuring that terms of service are of adequate duration (e.g., 8 to 10 years for department heads and deans) and that transitions of power are structured in such a way as to allow overlap across leaders. For example, some boards employ overlapping terms of relatively short duration (e.g., 2 to 4 years) that are renewable for a set number of terms (e.g., 2 to 3).20 At the end of each term, the institution and faculty member holding the position could assess whether the leader should continue in the role. For high-level positions, such as those of deans and department chairs, a single, longer term may provide better stability and consistency than recurrent smaller terms, but longer terms also mean that ineffective leaders may need to be tolerated longer. The ultimate structure of any term-limited position would need to be based on predefined goals and take into account the needs of the institution.

While adoption of term limits in U.S. and Canadian AMCs has been limited, a few notable institutions have implemented them. Indeed, the term limits used by the Mayo Clinic may offer a template for other institutions. At Mayo, department and division heads typically rotate every 8 years, and changes to compensation based on leadership roles are minimal (i.e., incoming leaders do not receive a “recruitment package”).38 Given the steady rotation of leadership, faculty view a leadership role more as a shared task rather than an earned position of power. This perspective fosters greater teamwork and collaboration among faculty. The term limits and rotating positions of authority provide means for more individuals to hold leadership positions, and hence, achieve more equitable power sharing.38 Since leadership positions are time limited and most leaders will return to clinical practice at the end of their tenure, this rotating system of leadership also incentivizes leaders to maintain their clinical roles and avoid disconnecting from clinical medicine as nonpracticing professional administrators.

The National Institutes of Health (NIH) recently introduced term limits as well.39 In an effort to bring greater equity to positions of power, branch chiefs at the NIH are limited to 12 years, in three 4-year terms. Similarly, at the University of British Columbia Medical School, leaders are limited to two 5-year renewable terms.40 Using these examples, I propose the following term limits: 8 years for executive positions of power (e.g., division heads, department heads, deans, presidents) in the form of two 4-year renewable terms and 10 years for educational leadership positions (e.g., clerkship directors, residency program directors) in the form of two 5-year renewable terms. These limits would provide ample time to achieve goals (e.g., completing a capital project) and to develop areas of expertise while at the same time allowing enough turnover to ensure representation of a more diverse group of individuals.

Although there are strong arguments for and against term limits, I believe the potential benefits of term limits—refreshed leadership, innovation, and equitable power sharing—may outweigh the downsides for some institutions. Institutions must take into account their specific needs and whether term limits can address those needs before instituting a system of planned leadership transitions. If proceeding with term limits, institutions should monitor the results and report the outcomes to establish and build an evidence base to guide further implementation.

Acknowledgments:

The author wishes to thank Dr. Alex Foster and Dr. Michelle Noelck for their helpful suggestions and edits.

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