The current system of academic promotion and tenure at academic medical centers primarily recognizes research, education, and clinical care but this system has been under stress as the roles and responsibilities of faculty have expanded. The promotion pathways do not adequately recognize the work of clinical faculty or new types of physician roles like physician-executives, creating a two-class system. The article argues it may be time to abandon rigid promotion pathways and instead more broadly recognize various forms of excellence across faculty roles.

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Samyukta Mullangi, MD, MBA1,2; Mitchell J. Blutt, MD, MBA3; Said Ibrahim, MD, MBA1
Author Affiliations | Article Information
February 25, 2020
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Promotional pathways for faculty at academic medical centers (AMCs) largely track along
3 missions: clinical care, research, and education. But this system has been under stress
for years, with data showing that clinical faculty members are less likely to be at higher
academic ranks, less satisfied with their progress on the promotion escalator, and more
likely to leave or at least express an intention to leave academic medicine.1,2
The elephant
in the room and the source of significant frustration for faculty is that the research mission
is often accorded greater recognition and visibility at AMCs, evidenced in how the concept
of tenure, with its associated reputational currency, is only granted to faculty members on
this track.
To complicate things further, narrowing operating margins and declining federal research
dollars have forced AMCs to restructure their operating models to better align with the
goals of their affiliated hospital system.3 These strategic imperatives have led to important
Is it Time to Reimagine Academic Promotion and Tenure?
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compositional changes in AMC physician faculty. For example, health systems, now
leaning more heavily on the generation of clinical revenue to sustain their enterprise, have
intensified hiring of clinical faculty members who are explicitly not on any promotion
pathway. In many places, these faculty members are hired directly by hospitals and work
without supervised trainees. There has also emerged a new breed of physicians—
physician-executives—who manage efforts in population health, build up internal
innovation centers, or lead strategic planning for health systems. Despite these physicians
spending most of their time in service to the institution, their contributions are not easy to
categorize, and many are relegated by default to the clinical track.
Thus, AMCs are increasingly saddled with an uneasy 2-class system of those on a
promotion pathway and those off, those with a natural academic home and those without,
those eligible for tenure and those not. In this article, we examine the history of the
academic promotion and ask if it is time to jettison it.
Although the system of promotion and tenure that forms the backbone of AMCs feels like
the beating heart of the academic faculty experience, the truth is that it is a relatively
recent phenomenon.4
It was not until after World War II and long after the Flexnerian
revolution of medical education (when medical schools began to affiliate more closely with
universities) that the tenure system, developed originally for faculty in the arts and
sciences, was coopted by medical schools. Places like Johns Hopkins led the way in hiring
full-time physiologists and anatomists, whose income was supported by salary rather than
private practice income. Certainly, this culture of research contributed to the subsequent
explosive growth of biomedical knowledge in the 20th century.
However, physician faculty at medical schools have always had fundamentally different
jobs than faculty members in the arts and sciences by way of their commitment to service.
In their practice of their craft, patient care, medical school faculty members are without
peers in the larger university system.5 In contrast, business school faculty members are
not required to provide consulting services to companies, and law faculty members are not
required to provide legal aid simply to keep the lights on. Thus, medical school faculty
members have always had a dual identity of sorts, as purveyors of academic knowledge at

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the medical school and generators of revenue for the hospital. Furthermore, the concept of
tenure has always been slightly irrelevant to clinicians. While tenure confers academic
freedom on liberal arts faculty and thus the ability to espouse unpopular ideas without fear
of immediate dismissal, there is no analogous protection given to clinicians. For instance, a
tenured physician who voices antivaccination views may lose his or her job,
notwithstanding the fact of tenure. Additionally, today’s physician faculty members, even
those with tenure, must continue to see patients or secure research grants to make their
salaries whole.6
As the scope of AMCs shifts, the current edifice of promotion and tenure starts to appear
dated. Defenders of the status quo, however, usually use 1 of 2 arguments. The first is that
not all work done at an AMC, despite being important, furthers the academic mission. This
argument, which belabors the point that the ideal academic clinician be the perfect blend of
research, clinical care, and education, is as unsatisfying as its underlying reductionist
assumptions. To start, few clinicians are truly able to manage this juggling act without
protected time within the workweek to meaningfully pursue all 3.7Furthermore, it discounts
the contributions of those whose work actually requires deep expertise; few aspiring
physician-executives are landing in leadership positions today without concomitant
degrees in management or public health, for example.
The second, somewhat associated counterargument, is that exclusion from the promotion
pathway is not actually hurting anyone. This argument suggests that promotion up the
ladder from assistant professor to associate and full professor positions is simply an
academic nicety, a titular rather than financial benefit. But if a reward system is truly so
toothless, should it be retained? Furthermore, this argument is actually quite disingenuous,
given that many leadership roles within the health system (and without) are contingent on
a candidate achieving a certain academic rank.
What would an alternative recognition system look like? Our suggestion: let us abandon
strictly codified pathways and move toward more broadly recognizing excellence (possibly
as voted by a plurality of one’s peers). After all, excellence comes in many varieties, from
providing excellent patient care to the formulation of new theories, teaching, engaging in

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1.
2.
3.
quality improvement, and academic leadership. As long as a faculty member demonstrates
consistency in excellence, it should not matter what form it takes. A move away from
specificity in requirements for promotion and toward generality in recognizing excellence
accomplishes several things; it accounts for the heterogeneity in faculty output;
acknowledges the increasing impossibility for a faculty member to do it all with respect to
teaching, research, and clinical service; and still remains enough of an external validator to
motivate faculty members to distinguish themselves. At a time when AMCs are competing
to retain the best and the brightest, it is time to broaden the tent of internal recognition.
Corresponding Author: Samyukta Mullangi, MD, MBA, Division of Health Care Delivery
Science and Innovation, Weill Cornell Medicine, 402 East 67th St, LA 202, New York, NY
10065 (sam9291@med.cornell.edu).
Conflict of Interest Disclosures: Dr Blutt reported personal fees from Consonance
Capital, Bako, Psychiatric Medical Center (PMC), and Kepro outside the submitted work
and membership on the board of the Commonwealth Fund, board of overseers of Weill
Cornell Medicine, board of overseers of the Wharton School, and board of overseers of the
School of Arts and Sciences at the University of Pennsylvania. No other disclosures were
reported.
Lowenstein SR, Fernandez G, Crane LA. Medical school faculty discontent:
prevalence and predictors of intent to leave academic careers. BMC Med Educ.
2007;7:37. doi:10.1186/1472-6920-7-37PubMedGoogle ScholarCrossref
Thomas PA, Diener-West M, Canto MI, Martin DR, Post WS, Streiff MB. Results of
an academic promotion and career path survey of faculty at the Johns Hopkins
University School of Medicine. Acad Med. 2004;79(3):258-264.
doi:10.1097/00001888-200403000-00013PubMedGoogle ScholarCrossref
Konstam MA, Hill JA, Kovacs RJ, Harrington RA, Arrighi JA, Khera A; Academic
Cardiology Section Leadership Council of the American College of Cardiology. The
academic medical system: reinvention to survive the revolution in health care. J Am
Coll Cardiol. 2017;69(10):1305-1312. doi:10.1016/j.jacc.2016.12.024PubMed
Google ScholarCrossref
Article Information
References

5. 12/21/2020 Is it Time to Reimagine Academic Promotion and Tenure? | Health Care Workforce | JAMA Health Forum | JAMA Network
https://jamanetwork.com/channels/health-forum/fullarticle/2762319 5/5
4.
5.
6.
7.
Fye WB. The origin of the full-time faculty system. Implications for clinical
research. JAMA. 1991;265(12):1555-1562. doi:10.1001/jama.1991.03460120069038
ArticlePubMedGoogle ScholarCrossref
Halperin EC. Is tenure irrelevant for academic clinicians? South Med J.
1995;88(11):1099-1106. doi:10.1097/00007611-199511000-00003PubMed
Google ScholarCrossref
Bickel J. The changing faces of promotion and tenure at U.S. medical schools. Acad
Med. 1991;66(5):249-256. doi:10.1097/00001888-199105000-00002PubMed
Google ScholarCrossref
Bland CJ, Seaquist E, Pacala JT, Center B, Finstad D. One school’s strategy to
assess and improve the vitality of its faculty. Acad Med. 2002;77(5):368-376.
doi:10.1097/00001888-200205000-00004PubMedGoogle ScholarCrossref