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Life without Tenure, Part 1

August 2005

When I began writing this column three years ago, my main goal was to help junior faculty and trainees achieve professional success by addressing career skills and topics not typically discussed in traditional training programs. Academic medicine likes to hold itself apart from more "mundane" careers such as business and law by stressing its lofty pursuit of research and teaching and its dedication to patient care. Trainees are told to focus on research and productivity without much attention to other skills vital to success in academics.

Let's face it, negotiating and dealing with issues such as job security and salaries are skills not developed during medical training. After all, house-staff salary scales for most accredited training programs are set by the NIH and thus are largely non-negotiable. And once accepted, whether it be to medical school or residency or fellowship, you need to do something truly terrible for the program to even consider letting you go, and even then, there are all kinds of remedial or assistance programs available.

The intense focus on clinical and research training during residency and fellowship results in junior faculty being unprepared for and potentially traumatized by soft money salaries and un-guaranteed promotional progression in academic medicine. By providing a written road map of the often byzantine, mazelike, tortuous path of academic medicine, I hoped that people would avoid obvious obstacles, pain and wasted energy. Money is often treated as a dirty subject. Simple economics drives the agendas of division directors, department chiefs and deans trying to balance the budget with diminishing clinical and government revenues. Hence, successfully in obtaining funding is perhaps the only guarantee of job security and promotion. Faculty with R01s are rarely denied advancement, regardless of abysmal teaching evaluations. This can seem disheartening to junior faculty who feel insignificant in an academic power structure that they don't quite grasp. They struggle to build their academic careers brick by brick with grants that are increasingly hard to obtain and never cover all the bills. The transition from assistant to associate professor can be an emotionally devastating, arduous process. The faculty member must run the academic gauntlet to prove that s/he is worthy of tenure. Unfortunately, confusion regarding the promotion and tenure process continues to exist for clinical faculty in many academic institutions. They must decide whether or not the prestige of a faculty appointment without a salary guarantee is sufficient to compensate for often poorer working conditions and lower salaries of academia.

To review, tenure, as defined by the Merriam-Webster's Online-Collegiate Dictionary, is the act, right, manner or term of holding something (as a landed property, a position or an office); especially: a status granted after a trial period to a teacher that gives protection from summary dismissal. Tenure implies that you have earned the long-term commitment of salary, personnel and research resources. Practically speaking, tenure has come to be seen as an academic perk, a reward to offset other, often more lucrative, career possibilities that the faculty member has passed up in order to stay in academia. Thus, you must prove your worthiness.

Tenure for doctors? Tenured positions are increasingly scarce in medical schools and the majority of clinically oriented medical school faculty hold non-tenure positions. So what is the value of tenure for most academic physicians? One of the earliest columns that I wrote, "Climbing the Academic Ladder and Why People Fall Off"(http://www.thoracic.org/women/careertalk/career0902.asp), discussed the promotion and tenure process, but skirted the actual issue of tenure as a measure of academic success. In this and next month's columns, I'll talk about some of the advantages and disadvantages of tenured versus non-tenured positions.

Together with academic due process and faculty self-governance, tenure is looked upon as a vital right that protects academic and intellectual freedom in institutions of higher education. More than this, tenure has come to be a measure of prestige that offers job security as an acknowledgement of excellence. In essence, tenured faculty may be released (i.e., fired) only for doing something really, really bad (bad enough to make front-page news, usually). This commitment lies at the heart of the creative freedom so cherished in academia. Tenure protects scientific research and just as importantly, political free speech. Think Galileo or Copernicus!

The concept of tenure, as it applies to medical school faculty, has evolved over the last 10 years. Most medical schools these days simply cannot afford to support their entire faculty because most of their funds are patient-generated. Some of you may remember the fiscal crises of the late 1990s that many medical schools faced and are still struggling with to this day. Hard money or guaranteed income is very limited. Typically, hard money comes in the form of tuition, endowment income or, at a public institution, state subsidies. Not surprisingly, full-time equivalents (FTEs) or other types of salary guarantees are extremely coveted and doled out cautiously by department or division chairs. But even a full FTE usually covers only part of a faculty member's salary. The remainder is soft money generated by grants and patient-derived income. What this means is that tenure at your institution may guarantee you nothing more than a title. It is important that you understand your contract to see if this is so.

In addition to economic concerns, "traditional" academics (i.e., arts and sciences colleagues) have argued that many professors of medicine are not entitled to tenure because they do not perform the same kind of work that they do, given that clinical responsibilities form a large part of what many academic physicians do. Since medical schools are not willing or unable to hire all the faculty that they need on a tenured basis, they have created parallel tracks with such titles as clinical professor, adjunct professor, research scientist or lecturer. On the surface, these positions appear no different from their tenured equivalents except that they may be part-time and/or focused on carrying out only one or two of the academic missions of teaching, research and service instead of all three.

Practically speaking, you need to understand the source(s) of your salary and understand the conditions required for promotion if only to understand under what terms you may be released. Since medical schools have adopted numerous models (endowed chairs, contracts, X-Y-Z funding) to help them deal with the issue of tenure and salary guarantees, it may be difficult to say how much of your salary is guaranteed. Non-tenured faculty may or may not enjoy the same fringe benefits (i.e., health and retirement) depending on their percent effort.

Furthermore, medical school faculty must remember that they are part of the larger academic community of their institution. While concerns regarding undergraduate curriculum may dim in comparison to patient care responsibilities, and the concept of academic freedom may seem remote for someone that is hospital-based, they are very real for the majority of your university colleagues. Conversely, most non-medical school faculty do not really understand the typical work day of their medical school colleagues. Not surprisingly, the productivity of many medical school faculty fails to meet expectations according to traditional measures. In other words, all that time and effort you put into being a "good" doctor means very little to most traditional academic promotion committees. Considering that you may have been hired to undertake these responsibilities, and have been hard-working and a team-player, being denied promotion can be confusing and, as I mentioned earlier, emotionally devastating.

Perhaps the importance of tenure is related to how your institution values you and your work. Tenure has never meant job security alone but carries with it the promise of academic freedom and protected time to perform research and to teach. For clinical faculty, being able to practice medicine in an academic institution offers the prestige associated with academics, the opportunity to interact with house-staff and participate in medical education. The opportunity to practice medicine in an academic setting provides challenges and diverse experiences not possible in private practice or industry. It is not just a "job," but a philosophy of life and service.

Next month: What to do? Life without Tenure, part II: The fading Promise of Academic Medicine.