ACADEMIA
AND
CLINIC
Faculty Tracks and Academic Success William N. Kelley, MD, and Jeoffrey K. Stross, MD
• In 1977, the Department of Internal Medicine at the University of Michigan implemented two specific faculty career tracks, the physician-scientist and clinicianscholar, to define more clearly the goals and expectations to which individuals should strive to achieve academic success. In response to the changing environment, a leadership track and a full-time clinical track were added. Although concerns about comparability, transfer between tracks, and research productivity were raised initially, they were alleviated as it became apparent that the ability to achieve tenure was similar in the physician-scientist and clinician-scholar tracks. The development of well-defined faculty tracks has facilitated the alignment of talents, training, and effort with career goals. It has also enabled us to protect the time of young investigators to pursue their research activities and to define the expectations for promotion for clinicians with a major commitment to patient care. Annals of Internal Medicine. 1992;116:654-659. From the University of Michigan Medical School, Ann Arbor, Michigan. For current author addresses, see end of text.
I n the mid-1970s it was clear that academic medicine was changing at a rapid pace and that further changes could be anticipated. The rapid-growth phase of the National Institutes of Health (NIH) had ended, and the resultant tightening of research funds from the NIH was clearly increasing the competitive nature of research funding. The developments in molecular and cell biology, along with an increasing emphasis on potential clinical relevance, were beginning to blend the research of the physician-scientist in a clinical department with that of faculty in basic science departments. Indeed, investigators from both clinical departments and basic science departments were competing through the same study sections for the same funds. Concomitant with these changes in the nature of funding in research, even more dramatic changes were occurring in the practice of medicine. The advent of new technologies; the dramatic increase in the use of invasive diagnostic and therapeutic procedures; and the expansion of third-party coverage for health care, including the development of Medicare and Medicaid, provided strong evidence that clinical revenues would be an increasing source of funds for clinical departments in academic health centers. Thus, an increasing demand for specialized clinical service was coming at a time when physician-scientists would require more protected time to successfully compete in the peer review system for research funding. 654
It became apparent that the expertise and time commitment needed to excel in the clinical arena would be incompatible with those needed to succeed in the research laboratory. Accordingly, it appeared that it would be increasingly difficult for a clinical department to be successful if the leadership continued to rely largely on "triple threat" faculty as they had in the past, with each individual contributing equally in the areas of education, research, and patient care. A wellbalanced department would need individuals who excelled in each area, and it was incumbent on departmental leaders to develop the mechanisms to recruit and retain the types of faculty who could meet departmental objectives. These mechanisms would need to be flexible and allow each person to develop to the maximum of his or her abilities. Faculty Track Development In 1977, we approached these challenges by creating two specific faculty career tracks, the physician-scientist and clinician-scholar tracks, in the Department of Internal Medicine at the University of Michigan (Table 1) (1). These two tracks were intended to define clearly for new faculty the expectations from the leaders in the department and to attempt to describe as clearly as possible the goals to which they should strive to be successful as academicians. Faculty in both tracks would have the same teaching responsibilities; each faculty member would commit approximately 20% of his or her time to teaching. Almost all of this teaching time would be spent serving as an attending physician in the ambulatory care setting for half a day per week and during monthly rotations each year on the inpatient and consultation services. Additional teaching time might relate to departmental and divisional teaching conferences, physical diagnosis, and related activities. The remainder of the time commitment, however, would be considerably different between individuals in the two tracks. The physician-scientists would commit the remainder of their time to research. They would be assigned research space and, indeed, would be provided substantial start-up support to allow them an opportunity to equip and provide personnel to initiate their laboratory activities. They would be involved in patient care only to the extent necessary to carry out their teaching responsibilities, maintain their clinical skills, and conduct their clinical research. On the other hand, clinician-scholars would spend approximately 50% of their time in direct personal patient care, that is, patient care provided in the absence of students, house officers, or fellows. The remaining 30% of their time would be available for research activities. They would not be provided a laboratory although they may be provided modest start-up funds that could be used for personnel, computers, travel, and supplies.
© 1992 American College of Physicians
Downloaded From: https://annals.org/ by a Scott Memorial Library User on 08/13/2017
Table 1. Faculty Tracks Variable Title Tenure seeking Site of activity Assigned research space Teaching (including teaching combined with patient care),* % of total time Research, % of total time Personal patient care, % of total time Annual guaranteed salary, % of total salary Annual incentive salary, % of total salary
PhysicianScientist
ClinicianScholar
Full-Time Clinical
Research
Professorial Yes Campus Yes
Professorial Yes Campus No
Clinical No Off-campus No
Research scientist No Campus Yes
20 80 0 100 0
20 30 50 50 50
5 0 95 25 75
0 100 0 100 0
* All patient care was to be provided as part of teaching responsibilities with little, if any, personal patient care provided in the absence of students, residents, and fellows.
A maximum salary was set each year for each faculty member. The full salary support for an individual in the physician-scientist track was essentially guaranteed so that they would have no financial incentive to expand their patient care activities and thereby reduce their time for research and teaching. Clinician-scholars would have total salaries that were somewhat higher than physician-scientists (perhaps 25%), but they would also be responsible for generating the clinical component of their salaries (approximately 50%). This portion of their salary would not flow to them unless it was generated by clinical activity. If an individual in the clinicianscholar track was successful in obtaining external research funding, such funds for salary could be used to offset clinical income, thus freeing up clinical time. It was felt that one key to success in the development of two parallel tracks would be the recognition that faculty in each track were equally important to the institution. Accordingly, both tracks were established as tenure-seeking tracks. In addition, a method was described that would allow an individual to shift from one track to the other. Transfer from the physician-scientist to the clinician-scholar track would take place if he or she was acknowledged as an excellent clinician and wished to transfer, and the faculty member had no research funding to support a laboratory and either had no grants submitted for at least 1 year or had no grants approved or funded over a 2- to 4-year timeframe. Transfer into the physicianscientist track would occur if the clinician-scholar received recurrent peer-reviewed grant funding for a 4-year period, and he or she wished to transfer. Because both tracks were tenure-seeking and the basic criteria in the department for promotion were identical and exceeded the institutional criteria, concerns about comparability were minimized. Given this situation, the distinctions could be and were made largely at the departmental level. Clinician-scholars were provided at least 50% of their time to generate their incentive income. A separate clinical facility, the Faculty Diagnostic Unit, was developed so that faculty in the clinician-scholar track would have a site where they could care for personal patients in the absence of students, residents, and fellows and where control over this requirement could be ensured. Most faculty worked diligently to earn their income. Although it was clearly easier for a procedurally oriented subspecialist to earn his
or her income than for other internists, there were no instances where an individual devoted 50% effort and was unable to generate the full incentive portion of salary. We also believed that an extensive process for institutional review and approval was essential to the success of this program because successful legal challenges would make implementation extremely difficult. The major areas of concern related to the need to generate up to 50% of one's salary, the reassignment of laboratory space, and criteria for transfer from one track to the other. Hence, after considerable discussion from 1976 to 1978, the proposal was taken through the formal review and approval process including departmental faculty and division chiefs, the Dean, the medical school Executive Committee, the university officers, and the Regents of the university. By 1 July 1978, the program was in place, current faculty were designated, and all newly recruited faculty in the department were identified with one of the two tracks depending on the variables previously approved. We planned to achieve a mix with 75% of the faculty in the physician-scientist track and 25% in the clinician-scholar track. This reflected our research mission and the need to set limits initially that could be re-examined over time. Faculty Track Evolution This two-track system for faculty was formally established at the same time that a faculty practice plan was being implemented. This allowed for the payment of salaries on an incentive basis. Many concerns were voiced at the onset: Would the clinician-scholars be viewed as second-class citizens? Would clinician-scholars maintain their research productivity when forced to earn a major portion of their salaries and still qualify for promotion? Was it fair to subsidize the research effort using clinically generated dollars? Would transfer between tracks occur and how would these be adjudicated? Each of these problems, along with several others, were discussed within the department. Leadership Track Several major changes were made over the years (Figure 1). First, it became clear that crisply defined tracks were important for junior faculty just beginning
15 April 1992 • Annals of Internal Medicine • Volume 116 • Number 8
Downloaded From: https://annals.org/ by a Scott Memorial Library User on 08/13/2017
655
their academic careers in a faculty setting, but it was considerably less important and, indeed, occasionally confusing to insist that division chiefs and faculty with major administrative responsibilities in the department maintain identity with one of the two tracks. Accordingly, we developed a "leadership track" as an approach to recognizing that such senior individuals in the department had a vast range of responsibilities that could not be handled within the narrow definitions of either the physician-scientist or clinician-scholar tracks. For example, administrative time became an important variable for these faculty. In addition, even the classical physician-scientist would be expected to spend more time with personal patient care as the expectations of the community changed as he or she took on new responsibilities such as division chief or associate chairman. The number of individuals identified with this track has ranged from 15 to 20 from the time of its implementation in 1982 to the present. Full-Time Clinical Track It also became clear that the nature of practice in an academic setting was beginning to change even more substantially than anticipated. The institution was beginning to develop a number of off-site satellites, and the number of patients was increasing dramatically. In addition, the institution established its own health maintenance organization that included a large number of enrollees. In many institutions this substantial increase in volume, particularly off site, would be handled by volunteer or part-time faculty. For various reasons, this was not appropriate at the University of Michigan at that time. Based on these new requirements, it became apparent that the limited time protected for the clinician-scholar to perform his or her academic activities would be significantly threatened. To prevent this challenge to the very existence of a clinician-scholar, a full-time clinical track was implemented (see Table 1). These individuals were based off campus, the track was not tenure-seeking, they had clinical titles (for example, Clinical Assistant Professor), and the physicians were virtually (> 95%) solely committed to patient care.
They were selected on the basis of their clinical abilities and were not subjected to the standard academic review by the Institutional Appointments and Promotions Committee. The total compensation for these individuals was set by the chair and was to be comparable to those in the clinician-scholar track, but only 25% of the salary would be guaranteed each year, with the remainder providing incentive related to their patient care activities. Once the full-time clinical track was established in 1986, appointments were made; at the present time 10 physicians are in that track. They accounted for 25 000 outpatient visits last year, approximately 20% of the departmental volume. Most of these visits were incremental and continued growth has been seen in the ambulatory clinics not staffed by the full-time clinical faculty. A relatively minor change was made in 1987. Incentive salary was initially calculated on the basis of 34% of gross billings because we did not want the faculty member to have an incentive to focus on payor mix nor did we want them to be concerned about the efficiency of collections. Because of reimbursement changes, confidence in the billing system, and increasing demands on the faculty, this incentive component was changed to 55% of collections. In addition, when a limit salary was achieved relatively early in the fiscal year, this was taken into account when the limit salary was set for the following year, thereby continuing to provide some financial incentive for clinical activity even when the faculty member was easily able to earn his or her incentive salary. Emeritus Track Given the implementation of the leadership and fulltime clinical tracks in the department, it was recognized that two other faculty tracks actually existed within the university, and in the department, and that these two tracks also needed to be formally identified. At the University of Michigan, as with almost every other university, emeritus faculty benefit from their faculty appointments. Therefore, an emeritus track was formally recognized.
Figure 1. Schema of the faculty tracks. Tenure-seeking tracks are indicated by the shaded boxes. 656
15 April 1992 • Annals of Internal Medicine • Volume 116 • Number 8
Downloaded From: https://annals.org/ by a Scott Memorial Library User on 08/13/2017
Table 2 . A Comparis on of Faculty• Tracks with Regard to FPublishing, Teachiirig, and Re:search Fuinding Faculty Track
Time to Action
Teaching (1 = Excellent to 5 = poor)
Publications
* (range) Physician-scientist Promoted (n = 25) Departed (n — 23) On trackt (n = 12) Clinician-Scholar Promoted (n = 8) Departed (n = 1) On track* (n = 8)
Research Funding
n(%)
ROl*
Funding Federal
Other
AND
CLINIC
Faculty Tracks and Academic Success William N. Kelley, MD, and Jeoffrey K. Stross, MD
• In 1977, the Department of Internal Medicine at the University of Michigan implemented two specific faculty career tracks, the physician-scientist and clinicianscholar, to define more clearly the goals and expectations to which individuals should strive to achieve academic success. In response to the changing environment, a leadership track and a full-time clinical track were added. Although concerns about comparability, transfer between tracks, and research productivity were raised initially, they were alleviated as it became apparent that the ability to achieve tenure was similar in the physician-scientist and clinician-scholar tracks. The development of well-defined faculty tracks has facilitated the alignment of talents, training, and effort with career goals. It has also enabled us to protect the time of young investigators to pursue their research activities and to define the expectations for promotion for clinicians with a major commitment to patient care. Annals of Internal Medicine. 1992;116:654-659. From the University of Michigan Medical School, Ann Arbor, Michigan. For current author addresses, see end of text.
I n the mid-1970s it was clear that academic medicine was changing at a rapid pace and that further changes could be anticipated. The rapid-growth phase of the National Institutes of Health (NIH) had ended, and the resultant tightening of research funds from the NIH was clearly increasing the competitive nature of research funding. The developments in molecular and cell biology, along with an increasing emphasis on potential clinical relevance, were beginning to blend the research of the physician-scientist in a clinical department with that of faculty in basic science departments. Indeed, investigators from both clinical departments and basic science departments were competing through the same study sections for the same funds. Concomitant with these changes in the nature of funding in research, even more dramatic changes were occurring in the practice of medicine. The advent of new technologies; the dramatic increase in the use of invasive diagnostic and therapeutic procedures; and the expansion of third-party coverage for health care, including the development of Medicare and Medicaid, provided strong evidence that clinical revenues would be an increasing source of funds for clinical departments in academic health centers. Thus, an increasing demand for specialized clinical service was coming at a time when physician-scientists would require more protected time to successfully compete in the peer review system for research funding. 654
It became apparent that the expertise and time commitment needed to excel in the clinical arena would be incompatible with those needed to succeed in the research laboratory. Accordingly, it appeared that it would be increasingly difficult for a clinical department to be successful if the leadership continued to rely largely on "triple threat" faculty as they had in the past, with each individual contributing equally in the areas of education, research, and patient care. A wellbalanced department would need individuals who excelled in each area, and it was incumbent on departmental leaders to develop the mechanisms to recruit and retain the types of faculty who could meet departmental objectives. These mechanisms would need to be flexible and allow each person to develop to the maximum of his or her abilities. Faculty Track Development In 1977, we approached these challenges by creating two specific faculty career tracks, the physician-scientist and clinician-scholar tracks, in the Department of Internal Medicine at the University of Michigan (Table 1) (1). These two tracks were intended to define clearly for new faculty the expectations from the leaders in the department and to attempt to describe as clearly as possible the goals to which they should strive to be successful as academicians. Faculty in both tracks would have the same teaching responsibilities; each faculty member would commit approximately 20% of his or her time to teaching. Almost all of this teaching time would be spent serving as an attending physician in the ambulatory care setting for half a day per week and during monthly rotations each year on the inpatient and consultation services. Additional teaching time might relate to departmental and divisional teaching conferences, physical diagnosis, and related activities. The remainder of the time commitment, however, would be considerably different between individuals in the two tracks. The physician-scientists would commit the remainder of their time to research. They would be assigned research space and, indeed, would be provided substantial start-up support to allow them an opportunity to equip and provide personnel to initiate their laboratory activities. They would be involved in patient care only to the extent necessary to carry out their teaching responsibilities, maintain their clinical skills, and conduct their clinical research. On the other hand, clinician-scholars would spend approximately 50% of their time in direct personal patient care, that is, patient care provided in the absence of students, house officers, or fellows. The remaining 30% of their time would be available for research activities. They would not be provided a laboratory although they may be provided modest start-up funds that could be used for personnel, computers, travel, and supplies.
© 1992 American College of Physicians
Downloaded From: https://annals.org/ by a Scott Memorial Library User on 08/13/2017
Table 1. Faculty Tracks Variable Title Tenure seeking Site of activity Assigned research space Teaching (including teaching combined with patient care),* % of total time Research, % of total time Personal patient care, % of total time Annual guaranteed salary, % of total salary Annual incentive salary, % of total salary
PhysicianScientist
ClinicianScholar
Full-Time Clinical
Research
Professorial Yes Campus Yes
Professorial Yes Campus No
Clinical No Off-campus No
Research scientist No Campus Yes
20 80 0 100 0
20 30 50 50 50
5 0 95 25 75
0 100 0 100 0
* All patient care was to be provided as part of teaching responsibilities with little, if any, personal patient care provided in the absence of students, residents, and fellows.
A maximum salary was set each year for each faculty member. The full salary support for an individual in the physician-scientist track was essentially guaranteed so that they would have no financial incentive to expand their patient care activities and thereby reduce their time for research and teaching. Clinician-scholars would have total salaries that were somewhat higher than physician-scientists (perhaps 25%), but they would also be responsible for generating the clinical component of their salaries (approximately 50%). This portion of their salary would not flow to them unless it was generated by clinical activity. If an individual in the clinicianscholar track was successful in obtaining external research funding, such funds for salary could be used to offset clinical income, thus freeing up clinical time. It was felt that one key to success in the development of two parallel tracks would be the recognition that faculty in each track were equally important to the institution. Accordingly, both tracks were established as tenure-seeking tracks. In addition, a method was described that would allow an individual to shift from one track to the other. Transfer from the physician-scientist to the clinician-scholar track would take place if he or she was acknowledged as an excellent clinician and wished to transfer, and the faculty member had no research funding to support a laboratory and either had no grants submitted for at least 1 year or had no grants approved or funded over a 2- to 4-year timeframe. Transfer into the physicianscientist track would occur if the clinician-scholar received recurrent peer-reviewed grant funding for a 4-year period, and he or she wished to transfer. Because both tracks were tenure-seeking and the basic criteria in the department for promotion were identical and exceeded the institutional criteria, concerns about comparability were minimized. Given this situation, the distinctions could be and were made largely at the departmental level. Clinician-scholars were provided at least 50% of their time to generate their incentive income. A separate clinical facility, the Faculty Diagnostic Unit, was developed so that faculty in the clinician-scholar track would have a site where they could care for personal patients in the absence of students, residents, and fellows and where control over this requirement could be ensured. Most faculty worked diligently to earn their income. Although it was clearly easier for a procedurally oriented subspecialist to earn his
or her income than for other internists, there were no instances where an individual devoted 50% effort and was unable to generate the full incentive portion of salary. We also believed that an extensive process for institutional review and approval was essential to the success of this program because successful legal challenges would make implementation extremely difficult. The major areas of concern related to the need to generate up to 50% of one's salary, the reassignment of laboratory space, and criteria for transfer from one track to the other. Hence, after considerable discussion from 1976 to 1978, the proposal was taken through the formal review and approval process including departmental faculty and division chiefs, the Dean, the medical school Executive Committee, the university officers, and the Regents of the university. By 1 July 1978, the program was in place, current faculty were designated, and all newly recruited faculty in the department were identified with one of the two tracks depending on the variables previously approved. We planned to achieve a mix with 75% of the faculty in the physician-scientist track and 25% in the clinician-scholar track. This reflected our research mission and the need to set limits initially that could be re-examined over time. Faculty Track Evolution This two-track system for faculty was formally established at the same time that a faculty practice plan was being implemented. This allowed for the payment of salaries on an incentive basis. Many concerns were voiced at the onset: Would the clinician-scholars be viewed as second-class citizens? Would clinician-scholars maintain their research productivity when forced to earn a major portion of their salaries and still qualify for promotion? Was it fair to subsidize the research effort using clinically generated dollars? Would transfer between tracks occur and how would these be adjudicated? Each of these problems, along with several others, were discussed within the department. Leadership Track Several major changes were made over the years (Figure 1). First, it became clear that crisply defined tracks were important for junior faculty just beginning
15 April 1992 • Annals of Internal Medicine • Volume 116 • Number 8
Downloaded From: https://annals.org/ by a Scott Memorial Library User on 08/13/2017
655
their academic careers in a faculty setting, but it was considerably less important and, indeed, occasionally confusing to insist that division chiefs and faculty with major administrative responsibilities in the department maintain identity with one of the two tracks. Accordingly, we developed a "leadership track" as an approach to recognizing that such senior individuals in the department had a vast range of responsibilities that could not be handled within the narrow definitions of either the physician-scientist or clinician-scholar tracks. For example, administrative time became an important variable for these faculty. In addition, even the classical physician-scientist would be expected to spend more time with personal patient care as the expectations of the community changed as he or she took on new responsibilities such as division chief or associate chairman. The number of individuals identified with this track has ranged from 15 to 20 from the time of its implementation in 1982 to the present. Full-Time Clinical Track It also became clear that the nature of practice in an academic setting was beginning to change even more substantially than anticipated. The institution was beginning to develop a number of off-site satellites, and the number of patients was increasing dramatically. In addition, the institution established its own health maintenance organization that included a large number of enrollees. In many institutions this substantial increase in volume, particularly off site, would be handled by volunteer or part-time faculty. For various reasons, this was not appropriate at the University of Michigan at that time. Based on these new requirements, it became apparent that the limited time protected for the clinician-scholar to perform his or her academic activities would be significantly threatened. To prevent this challenge to the very existence of a clinician-scholar, a full-time clinical track was implemented (see Table 1). These individuals were based off campus, the track was not tenure-seeking, they had clinical titles (for example, Clinical Assistant Professor), and the physicians were virtually (> 95%) solely committed to patient care.
They were selected on the basis of their clinical abilities and were not subjected to the standard academic review by the Institutional Appointments and Promotions Committee. The total compensation for these individuals was set by the chair and was to be comparable to those in the clinician-scholar track, but only 25% of the salary would be guaranteed each year, with the remainder providing incentive related to their patient care activities. Once the full-time clinical track was established in 1986, appointments were made; at the present time 10 physicians are in that track. They accounted for 25 000 outpatient visits last year, approximately 20% of the departmental volume. Most of these visits were incremental and continued growth has been seen in the ambulatory clinics not staffed by the full-time clinical faculty. A relatively minor change was made in 1987. Incentive salary was initially calculated on the basis of 34% of gross billings because we did not want the faculty member to have an incentive to focus on payor mix nor did we want them to be concerned about the efficiency of collections. Because of reimbursement changes, confidence in the billing system, and increasing demands on the faculty, this incentive component was changed to 55% of collections. In addition, when a limit salary was achieved relatively early in the fiscal year, this was taken into account when the limit salary was set for the following year, thereby continuing to provide some financial incentive for clinical activity even when the faculty member was easily able to earn his or her incentive salary. Emeritus Track Given the implementation of the leadership and fulltime clinical tracks in the department, it was recognized that two other faculty tracks actually existed within the university, and in the department, and that these two tracks also needed to be formally identified. At the University of Michigan, as with almost every other university, emeritus faculty benefit from their faculty appointments. Therefore, an emeritus track was formally recognized.
Figure 1. Schema of the faculty tracks. Tenure-seeking tracks are indicated by the shaded boxes. 656
15 April 1992 • Annals of Internal Medicine • Volume 116 • Number 8
Downloaded From: https://annals.org/ by a Scott Memorial Library User on 08/13/2017
Table 2 . A Comparis on of Faculty• Tracks with Regard to FPublishing, Teachiirig, and Re:search Fuinding Faculty Track
Time to Action
Teaching (1 = Excellent to 5 = poor)
Publications
* (range) Physician-scientist Promoted (n = 25) Departed (n — 23) On trackt (n = 12) Clinician-Scholar Promoted (n = 8) Departed (n = 1) On track* (n = 8)
Research Funding
n(%)
ROl*
Funding Federal
Other
