Tenure in the Medical School

This report, approved in 1999 by the Association’s Committee A on Academic Freedom and Tenure, is a revision of a report approved for publication by Committee A in November 1995.


Introduction and Background

This report and proposed policy statement result from ongoing concerns within the American Association of University Professors regarding the changing nature of academic medical cen­ters in American higher education and the impact, evident or potential, of those changes on questions of faculty status and academic freedom within such centers.1

Until the early twentieth century, few medical schools were affiliated with universities, most being freestanding proprietary schools of varying standards. The faculty were largely physi­cians whose income was derived from the private practice of medicine and fees from students. Reforms in medical education early in this century were influenced by the Flexner report and fostered by the American Medical Association, and required the affiliation of medical schools with universities along European (particularly German) lines, with the concurrent establish­ment of basic­-science departments for research and teaching.2 The new university-affiliated medical schools developed full­-time, salaried faculty, some of whom were not physicians but basic scientists by training, and their arrival coincided with the formation of the American Association of University Professors and the development of policies and standards relating to academic freedom and tenure.

The rapid post–World War II growth of medical schools resulted in major changes, includ­ing the increase in the number of medical students, curricular revision, augmented postgradu­ate medical training in clinical specialties (residency programs), greater emphasis on research and patient care, and the creation of non-­tenure-­track lines of full­-time as well as part-­time fac­ulty. These expanded responsibilities required an expansion in the total number of faculty as well, and altered the relationship between the faculty and the medical school and also between the medical school and the university. Faculty salaries have become increasingly dependent on income from outside sources (e.g., research grants for faculty in basic-­science departments and for non-physician scientists in clinical departments and fees from patient­-care activities for physician faculty). Academic advancement and tenure have become increasingly based on scholarly research and publications, and less on teaching and service.

Medical schools have a unique status among institutions of higher learning. Whether state or private, they are large institutions which, with few exceptions, are part of or affiliated with universities. They encompass diverse educational and research interests ranging from molec­ular biology to preventive medicine. They rely on affiliated hospitals and clinics for patients for medical practice and teaching of students, postgraduates (residents), and fellows.

If medical schools are very different from the universities with which they are affiliated, they are also very different institutions from what they were three decades ago. Then a medi­cal school looked a lot more like the rest of the university. Its revenues came from the same combination of sources, but the proportions of that income were very different from what they are now. Revenue now comes from tuition and fees, state and local governments, federal funds (research and other income), endowment, contract research, and medical services.

The number of medical students has not grown in recent years, but that number is about double that of thirty­-five years ago.3 The number of faculty members, however, has grown dra­matically over that period of time. Today there are about 75,000 faculty members in medical schools. A very substantial number of the newly added faculty members are appointed to full­-time positions in clinical departments, but most of their responsibilities are in billable patient care and clinical teaching (supervising medical students in practice settings). The balance between income-­generating patient services and the teaching of students weighs heavily on the side of the former. The rapid growth in the number of clinical faculty members, a number about ten times as large as thirty­-five years ago, is almost entirely due to its role in producing rev­enue, as the number of students has only doubled since then.

Because of the volatility of the environment in which medical schools function, now and in the future, it is especially appropriate that the role of tenure as the guarantor of academic free­dom in these institutions receives examination. Faculty members in medical schools face prob­lems with respect to tenure different from those faced by faculty members in other parts of the university. The expectation that tenured faculty members create their own salaries from the provision of medical services or research grants will cause increasing problems as resources become scarcer. For example, reliance on external funding for salary support poses special problems for non-physician tenured and tenure-­track faculty researchers in clinical depart­ments. If these faculty members lose research grant support, they cannot turn to medical prac­tice to earn a salary. Their vulnerability is greater than that of tenured physician faculty mem­bers who can teach medical specialties and who can earn income by medical practice, as well as that of tenured faculty members in basic-science departments who can teach in their aca­demic specialties.

As a provider of health care, a medical school needs income derived from the clinical ser­vices to provide a large share of the salaries of the physician faculty. Physicians who provide patient care include tenure-­track and tenured faculty, non-tenure-track faculty, and resident and subspecialty physicians in training. The non-tenure-track physician faculty, who are not necessarily required to be scholars and may do little teaching, provide much of the care of patients, whose fees add to the income of the medical school.

The modern medical school, in short, has the attributes of a business enterprise with large­ly individual entrepreneurial activities in both patient care and research. Those faculty mem­bers so involved are counted on to bring in funds not only to underwrite salaries for support­ing personnel, laboratory equipment and supplies, and those indirect costs necessary to main­tain the infrastructure of the enterprise, but also to underwrite faculty salaries, including in many cases a portion of the salaries of tenured faculty members. Academic advancement of fac­ulty in basic-science departments and non-physician faculty in clinical departments is dispro­portionately dependent upon scholarly research as compared with teaching and service, and the research in turn is disproportionately dependent on salary support from research grants. The heavy dependence on external funding for salary support can divert faculty dedication and effort away from teaching and university service toward research or patient care to maintain their income and status.

The challenges facing the medical school have been succinctly stated by the president of the Association of American Medical Colleges (AAMC), Dr. Jordan J. Cohen:

The existence of tenure in medical schools represents a linkage to the broader academic culture of the university, with its traditional devotion to a free exchange of ideas without threat of economic penalty. Yet medical schools, because of their increased involvement in the real world of health­-care delivery, are also linked to the corporate culture, with its brutal devotion to productivity without guarantees of economic security. The clash of these cultures is reaching deafening proportions and will challenge the most adroit aca­demic administrators. If medical schools are to succeed, they must avoid the Scylla of an ivory­-tower disregard of new competitive realities and the Charybdis of a corporate sell­out of academic values.4

In this report Committee A has attempted to maintain an awareness of precisely those twin dangers.


Issues with Respect to Association Policy

The general concern of Committee A is whether medical schools support, or are prepared in the near and long-­term future to support, the policies and procedures relating to academic free­dom, tenure, and due process that have been promulgated by the AAUP since its founding. The need for a review of Association policy is suggested by the questions raised by some med­ical school administrators and faculty about the validity of and need for tenure, along with instances of abridgment of academic freedom and due process in medical schools. Among the issues we have noted are (1) the appearance of de facto departures from standards, for exam­ple, in regard to the application of the probationary period; (2) the increasing use of non-­tenurable full-­time as well as part­-time faculty; (3) in some, though not all, medical schools, an apparently inadequate role for medical school faculty in institutional governance, particularly in terms of faculty status, working conditions, and curriculum; and (4) a concern about possi­ble intrusion by outside agents (e.g., state legislatures, Congress, licensing authorities) on gov­ernance and curriculum.

Although there is no doubt that the intensity of debate regarding the future of tenure in medical schools is considerably heightened as a result of the pressures we have been outlining, recent studies indicate that tenure in some form remains at the core of the faculty staffing poli­cies of such schools.5 The issue of tenure is more dramatically highlighted in the drop in the proportion of clinical faculty with tenure or on the tenure track.6 Within the tenure track, there is growing belief that a six-­year probationary period may be inadequate “for basic-science fac­ulty to establish themselves as independent investigators, especially given the competition for research funding.” If tenure is suffering erosion, it has not yet endured a frontal attack.

But even where the presence of tenure suggests the reassuring persistence of the system, there is solid evidence that the financial assurances of that system are being defined in a more limited way: that is, in connection with the percentage of institutional “hard money” in the tenure line. Unlike the situation in other academic units in modern American colleges and universities, it is not uncommon in medical schools to have tenure guarantees attached to, say, 20 or 30 percent of a faculty member’s full-­time appointment, with the remainder of the salary dependent on the procurement of external funding. Inasmuch as the 1940 Statement of Principles on Academic Freedom and Tenure, drafted and endorsed by the AAUP and the Asso­ciation of American Colleges and Universities and carrying the endorsement of more than 200 educational and professional associations, links tenure not only to “freedom of teaching and research and of extramural activities,” but also to “a sufficient degree of economic secu­rity to make the profession attractive to men and women of ability,” there would seem to be involved in appointments of the sort just described a very real question as to precisely what tenure means under conditions that protect only a portion of the faculty member’s income. A reasonable interpretation of the 1940 Statement would seem to imply that the ability of the faculty member to defend academic freedom, his or her own or the principle in general, is linked to whether the salary is adequate to the maintenance of financial independence.7

At the same time, the enormous diversity of medical-­school programs and of the variety of faculty who teach in them suggests that certain kinds of appointments were not foreseen by, and in any case not intended to fall within the ambit of, the 1940 Statement. In contrast to aca­demic faculty of the sort envisioned by that statement, academic physicians deal directly with the general public (patients) in an income-­producing environment. Their relationship to the institution with which they are affiliated is therefore fundamentally unlike that of the full-­time teachers and investigators who are described in the statement. We acknowledge that no policy adopted by the Association with respect to the academic culture of medical schools can com­mand the adherence of those schools without taking into account the nature of the medical enterprise. Nonetheless, we believe that existing Association policy can convincingly address many of those realities.8

The subcommittee acknowledges that medical schools to some extent, and increasingly, par­take of the nature of corporate as well as academic enterprise. (Here we would content ourselves with noting that corporations are not by definition incapable of offering appropriate guarantees of appointment.) Association policy must be flexible enough to address this question in a prin­cipled manner while being persuasive in terms of policy guidance to those engaged in the daily work of medical education. We also believe, however, that the presence of income-­generating activities in no way weakens the claim of faculty members in those schools to the protections of academic freedom and tenure consistent with the particular role that a given faculty member plays. To the extent that medical schools, and academic health centers, are academic institutions, and that an appointment in them is subject to those expectations that apply to tenured and tenure­-track appointments in other disciplinary areas of the university, we see no basis for conceding that such appointments are immune from the application of Association standards. To the extent that an appointment in, for example, a teaching hospital, with perhaps peripheral instructional duties and the expectation of the generation of clinical income, is essen­tially that of a practitioner, we do not assert that the award of tenure is necessarily appropriate. Rather, we would argue that such classes of faculty should enjoy academic freedom, including, but not restricted to, the right to speak on institutional policy, and that they should be provided with protections against the application of unreasonable or capricious sanctions, such as precip­itate dismissal, without the opportunity for a hearing, during a stated term of appointment. An important part of the responsibility for ensuring these conditions lies with the tenured faculty of the institution, in the context of a sound system of shared governance.

For the goal of quality to be implemented in a qualitatively sound way, the faculty members who offer medical education under substantially the same expectations of performance appli­cable to tenure­-track faculty in other disciplines at that institution must have the same oppor­tunity to benefit from freedom of inquiry, in teaching, research, and clinical practice, that ensures high quality in other areas of the academic enterprise. This includes the customary assurances of peer review and the right of appeal (rather than the mere delegation of review to officers of the medical­-school administration), a probationary period consonant with AAUP standards, a level of participation in the governance of the medical school appropriate to the particular kind of faculty appointment, and sufficient economic security to provide a safeguard for the exercise of academic freedom by all faculty.9 There should be collegial development of policies regarding laboratory space, clinical and other work assignments, research and space resources, and procedures that encourage the resolution of differences through peer review. In short, after giving all due allowance to the specific realities of the teaching and research envi­ronment in medical schools, we do not believe that they are so peculiar as to warrant placing all faculty in such schools beyond the academic pale, that is, outside the generally accepted standards set forth in the 1940 Statement and derivative policies of this Association.

 

Statement of Policy

1. The multiple purposes of an academic medical school have led to a variety of academic appointments—tenured, tenure-track, and non-tenurable—in which teaching, research, service, clinical practice, and patient care are given different weights and emphases. To the extent that these functions are all designated by traditional academic titles, however modified (e.g., clinical associate professor), they warrant the assumption of faculty status that brings the holders of those titles within the ambit of applicable Association policies and procedures, and hence the protections appropriate to a particular status.

2. Where the configuration of duties is such as to suggest the advisability of an appointment in a non-tenure-track position, a starting point for considering the obligations of the med­ical school may be found in the Association’s 1993 report, The Status of Non-tenure-track Faculty, for all classes of faculty, full or part time. Where the exigencies of particular kinds of faculty appointments may require exceptions to the standards set forth in that docu­ment, those exceptions should be specified after meaningful consultation with the appro­priate faculty bodies in the medical school.

3. The Association has never countenanced the creation of large classes of faculty in cate­gories other than tenured, tenure track, and visiting (or other appointments designated as short term with a terminus understood by both parties to the contract). To the extent that a faculty appointment at a medical school resembles a traditional academic appoint­ment, with clearly understood obligations in teaching, research, and service, the burden of proof on the institution is greater to justify making the appointment to a non-tenure-track position.

4. Tenure in a medical school should normally be awarded to a faculty member on the basis of the probationary period as defined in the 1940 Statement, viz:

Beginning with appointment to the rank of full­-time instructor or a higher rank, the probationary period should not exceed seven years, including within this period full­-time service in all institutions of higher education; but subject to the proviso that when, after a term of probationary service of more than three years in one or more institutions, a teacher is called to another institution, it may be agreed in writ­ing that the new appointment is for a probationary period of not more than four years, even though thereby the person’s total probationary period in the academic profession is extended beyond the normal maximum of seven years. Notice should be given at least one year prior to the expiration of the probationary period if the teacher is not to be continued after the expiration of that period [see also the Asso­ciation’s Standards for Notice of Nonreappointment (1964)].

We note a number of devices in the medical-­school setting to lengthen the probationary period, for example, by allowing adequate time for persons in clinical positions to seek board certification, time devoted to patient care rather than research. While the complexi­ties with respect to clinical practice may make such arrangements not only useful, but also beneficial to the clinical faculty member, we see no reason to consider the extension of such a practice to researchers in the basic sciences when expectations for the award of tenure conform to those extant in connection with appointments elsewhere in the university.

5. The sources of funding for positions in academic medical schools vary perhaps more great­ly than in other units of the university, with the faculty member being expected in many cases to make up a designated portion of his or her salary from patient care or research. The 1940 Statement of Principles stipulates that tenure is a means not only to academic freedom, but also to “a sufficient degree of economic security to make the profession attractive to men and women of ability.” Except, as is sometimes the case, where the reward of rank and tenure is purely honorific, all tenured and tenure-track faculty should be guaranteed an assured minimum salary adequate to the maintenance of support at a level appropriate to faculty members in the basic sciences, and not merely a token stipend, on a formula to be determined by the administration and board of trustees after consultation with a represen­tative body of the faculty. The unilateral administrative abrogation of a portion of that salary, absent a prior understanding as to the extent of its guarantee, may reasonably be interpret­ed not as an exercise of fiduciary responsibility but as an attack on the principle of tenure. While the same minimum may not apply in the case of non-tenure-track faculty, those fac­ulty should have a clearly understood and contractually enforceable expectation of a stipu­lated salary that cannot be unilaterally or arbitrarily abridged during the appointment peri­od. Although the extent of economic security may be subject to interpretation, due process must be assured for all faculty regardless of the nature of the appointment.

6. Since medical schools, whether freestanding or part of a larger institution, demonstrably engage many of their faculty in the traditional areas of teaching and research, the partic­ipation of the faculty in governance is as essential to educational quality in the medical school context as in any other part of the university. According to the Association’s 1966 Statement on Government of Colleges and Universities,

The faculty has primary responsibility for such fundamental areas as curriculum, subject matter and methods of instruction, research, faculty status, and those aspects of student life which relate to the educational process. On these matters the power of review or final decision lodged in the governing board or delegated by it to the president should be exercised adversely only in exceptional circumstances, and for reasons communicated to the faculty.

The level of faculty participation, of course, may be adjusted in individual cases to take into account such considerations as the tenurable or non-tenurable nature of the appointment, as well as full­- or part-­time status, though we suggest that a functional definition of the faculty member’s role ought to be the chief determinant. We have seen no compelling argument why the faculty of such schools should exercise a more limited influence in those schools than do faculty elsewhere in higher education, especially since in an academic health center a large portion of the budget may be generated by faculty in the form of clinical income as well as external grants. Key to the role of med­ical faculty, for the purposes of the present report, is the opportunity to define the terms and conditions of faculty employment, including such appointments as are necessary to meet institutional needs, and procedures for the award of tenure under Association­-sup­ported standards.

 

Conclusion

The Association has long held that academic tenure is not merely, or even most importantly, a form of job security, but rather an instrument for the protection of “the common good.” In serv­ing that function, a system of tenure, properly applied, is a guarantor of educational quality. We question whether any institution of higher education or one of its components, whether the purpose be undergraduate, graduate, or professional education, can provide such educational quality without that reasonable assurance of stability that helps ensure the commitment of its faculty members to freedom of inquiry in teaching and research and to the preparation of its students.

 

Notes

1. Much of the background section of this report has been adopted freely (and with thanks) from a 1994 report by an AAUP Task Force on Medical Schools.

2. Abraham Flexner, Medical Education in the United States and Canada (Boston: Merrymount Press, 1910; Carnegie Foundation for the Advancement of Teaching, Bulletin #4); Lester S. King, American Medicine Comes of Age, 1840–1920 (Chicago: American Medical Association, 1984); Paul Starr, The Social Transforma­tion of American Medicine (New York: Basic Books, 1982).

3. Robert F. Jones, American Medical Education: Institutions, Programs, and Issues (Washington, D.C.: Asso­ciation of American Medical Colleges, 1992), 10.

4. Jordan J. Cohen, “Academic Medicine’s Tenuous Hold on Tenure,” Academic Medicine 70 (1995): 294.

5. The conclusion of Robert F. Jones and Susan C. Sanderson, “Tenure Policies in U.S. and Canadian Med­ical Schools” (Academic Medicine 69 [1994]: 772–78), is that “medical schools have adapted tenure policies to allow themselves flexibility in meeting their academic and clinical missions. The forces driving schools to fashion unique faculty appointment arrangements are not dissipating. Tenure is likely to continue in the academic medical center of the future but to play a diminished role.”

6. “In 1983, 30,856 clinical faculty were listed on the FRS [Association of American Medical Colleges Fac­ulty Roster System], with 59 percent in tenure streams . . . By 1993, the number of clinical faculty listed on the FRS had nearly doubled, to 58,607. Only 47 percent were in tenure streams: 26 percent with tenure and 21 percent on track” (Jones and Sanderson, “Tenure Policies,” 773).

7. Practices vary widely with respect to the percentage of clinical appointments that may be tenured, and in some cases the tenured portion may be so negligible as to be of little concern to the clinical faculty mem­ber. The situation has become much more complex since the time of the 1940 “Statement,” and its framers doubtless would not have envisioned the complexities that have emerged. We suggest using a basic-science salary line as a guidepost for determining salary guarantees for clinical faculty members. The faculty of the particular school should be involved in arriving at a specific recommendation. Creative approaches not overtly at odds with existing Association policy seem possible. Thus, one school represented on the sub­committee has adopted a commitment to support such a faculty member at the fiftieth percentile at his or her academic rank as reported annually by the AAMC, or the present salary of the individual, whichever is less.

8. Although dealing primarily with term contracts in the area of sponsored research, the Association’s 1969 “Report of the Special Committee on Academic Personnel Ineligible for Tenure” (AAUP, Policy Docu­ments and Reports, 9th ed. [Washington, D.C., 2001], 88–91) acknowledges a category of employment, “con­tract research teams,” to which “traditional concepts of academic freedom and tenure do not apply.” It also argues, however, that “whenever academic institutions designate full-­time researchers as faculty members, either by formal appointment or by conferring the titles of instructor, assistant or associate professor, or professor, those researchers should have all the rights of other faculty members.” In the case of faculty members whose title is modified by the designation “clinical,” this issue now presents itself in a new light which we believe needs to be addressed here. More reluctantly, but with the awareness that the Associa­tion must nonetheless take account of changing realities, AAUP’s Committee on Part­Time and Non-tenure-track Appointments has developed, and the Association’s Council (1993) approved, a document setting forth the basic protections that should be applied to non-tenure-track faculty: “The Status of Non-tenure-track Faculty” (ibid., 77–87; see Statement of Policy, point 2, in this document).

9. In medical schools, the extent of the inclusion in departmental and faculty governance structures will depend on the extent to which the particular faculty member has responsibility for organizational or instructional matters that go beyond the specific, part­time instructional function for which he or she was appointed. For example, representation on a faculty curriculum committee by a part­time clinical faculty member who has been asked to organize student rotations in primary­care physicians’ offices might seem reasonable. Likewise, the inclusion of a full­-time non-tenure-track researcher on a faculty research com­mittee might be deemed appropriate.