Extract
By providing strong role models for medical students
and residents, full-time medical school faculty members catalyze
the renewal of their specialties. Not only are some students and
residents attracted to specific specialties as a result of interactions
with the faculty, but also some trainees are attracted to academic
positions themselves. While faculty members may move away from the
university and into private practice, job changes in the opposite
direction are far less common.
By providing strong role models for medical students
and residents, full-time medical school faculty members catalyze
the renewal of their specialties. Not only are some students and
residents attracted to specific specialties as a result of interactions
with the faculty, but also some trainees are attracted to academic
positions themselves. While faculty members may move away from the
university and into private practice, job changes in the opposite
direction are far less common.
The university loses expertise and continuity for residents and
students as well as for patient care when a clinician leaves a full-time
academic position for private practice. In an effort to identify
the reasons that orthopaedic surgeons make such a career change,
I analyzed the survey results of ninety-two orthopaedic surgeons
who had left full-time academia for private practice between 1994
and 1998. The information may be useful for comparisons with other
specialties and other time periods. Awareness of such information
by deans, department chairs, and faculty members, both present and
potential, may allow for better recruitment and retention of this
valuable resource.
My colleagues and I recently reported the results of a large
study, entitled "ÂAcademic Longevity and Attrition
of Full-Time Orthopaedic Faculty Members," in The
Journal1. We collected
data on 1777 orthopaedic surgeons who had held full-time academic
positions at eighty-two American universities at any time between
1959 and 1998 inclusively. At the time of analysis, our data were
more than 99% complete for the following items: birth year,
institution or institutions where the individual had served, subspecialty
(if any), year that the individual had started on the faculty, year
that the individual had left the faculty (if applicable), and next
activity (another academic position, private practice, retirement,
or death) (if applicable). The 134 orthopaedists in the Âindex
study who moved to private practice during the most recent five-year Âperiod
(1994 to 1998) became the subjects of the present study. They represented
fifty-two of the institutions included in the index study.
In July 1999, the study subjects received a questionnaire requesting
information regarding why they had left academia for private practice.
A self-addresseÂd, stamped envelope was included to facilitate
response. The questionnaire was sent again to those who had not
responded within eight weeks after the first mailing. Of the 134
questionnaires, ninety-two (69%) were completed and returned,
and they provided the data for this report.
The respondents were first asked to verify data that we had collected
previously, including name, birth year, institution or institutions
at which they had served, year that they had started on the faculty,
and year that they had left the faculty. This was followed by six
yes/no questions, which are presented in Table I.
These questions were followed by twenty-six items, to
which the subjects responded by marking a horizontal, 10-cm-long
visual analog scale. For the first twelve of these items, the left
end of the scale was labeled "no effect" and the
right end was labeled "critically important." Each
item was prefaced with the statement: "Please place an
x on each line regarding the importance of the following factors
on your decision to go into private practice." The factors
were patient volume and/or mix, physical resources for
practice (operating and clinical facilities, time, office space, and
support personnel), spouse’s career/concerns,
geographical location, level of financial compensation, level of
financial autonomy, resources for research (time, accessibility
to basic scientists, laboratory facilities, and financial support),
achieving tenure, departmental leadership, institutional leadership,
and other factors.
For the next ten items (queries 19Â through 28), the
left and right ends of the visual analog scale were labeled "low" and "high," respectively.
The first five items were prefaced by the statement, "When
you started on the full-time faculty, rate your commitment to:".
The next five items were prefaced by the statement, "When
you left the full-time faculty, rate your commitment to:". The
items to be rated on the visual analog scale for both statements
were clinical practice, basic research, clinical research, teaching,
and administration.
For the final four items, the left and right ends of the visual
analog scale were labeled "less" and "more," respectively.
These items were prefaced by the statement, "Compared to
your academic position, rate your current level of:". The
items were professional satisfaction, financial compensation, free
time, and overall sense of well-being.
The final portion of the questionnaire contained two items: "What
changes at your former faculty position might entice you to return
to full-time academics?" and "Please feel free
to elaborate on any of your responses or to add other comments." Each
item was followed by 1.5 in (3.8 cm) of blank space for the respondents
to write comments.
The data were compiled in Excel (Microsoft, Redmond, Washington)
and were analyzed with Stata (Stata, College Station, Texas).
The average age (and standard deviation) of the respondents when
they started their faculty positions was 35.5 ± 5.4
years (range, twenty-seven to fifty-seven years). The average duration
that the respondents served on the full-time faculty was 6.5 ± 5.4 years (range, less than one year to twenty-three
years). The respondents’ average age when they left their
full-time faculty positions for private practice was 42.1 ± 7.0 years (range, twenty-nine to sixty-eight years).
With regard to these Âvalues, there were no significant
difÂferences between the ninety-two respondents and the forty-two
nonrespondents.
The responses to the first six yes/no questions, which
are listed in Table I,
indicate that most of the respondents had joined faculties at institutions
other than where they had gone to medical school or where they had
performed their residency and fellowship; that most had become board-certified
during their time on the full-time faculty; and that, with four
exceptions, they had departed voluntarily.
The next twelve questions were aimed at determining the principal Âreasons
that the respondents had left the full-time faculty for private
practice. The averages and standard deviations for all ten factors
about which the respondents were queried are presented in Table II. The most
important factors related to departure were issues of institutional
and departmental leadership, followed by level of financial autonomy
and then by level of financial compensation. Nineteen respondents
(21%) listed additional factors that were Âimportant
in their decision, such as "politics," "bureaucracy," "career
advancement," "no mentoring," "inefÂficiency," and "poor
management." However, these additional responses were too
few and too varied to be analyzed statistically.
Queries 19 through 28 focused on the respondents’ commitment
to various career aspects when they joined and left the full-time
faculty (Table III).
On starting their full-time faculty positions, the respondents felt
the greatest commitment to clinical practice and teaching and the
least commitment to administration; commitments to basic and clinical
research were ranked in Âbetween. On the respondents’ departure
from the full-time faculty, their commitment to clinical practice
had Âincreased significantly and their commitment to basic
and clinical research and to teaching had decreased significantly
(p < 0.01 for both). There was no significant change in
the commitment to administration.
The responses to queries 29 through 32 indicate that the respondents
were generally pleased with their decision to change from a full-time
faculty position to private practice when they were polled one to
five years after the decision (Table IV).
Fifty-eight respondents wrote comments to query 33, "What changes
at your former faculty position might entice you to return to full-time
academics?" Some noted multiple factors. The most common
factor, noted on twelve questionnaires, was in the realm of leadership;
seven comments were related specifically to departmental leadership,
four were related to the medical school and hospital administration,
and one was nonspecific. Eleven respondents mentioned a need for
increased autonomy, both for the department within the medical school
and for the individual faculty member within the department. Eleven respondents
mentioned money and finances, both in terms of better compensation
and in terms of "stability" and "restructured practice
plan." Eleven respondents stated that no factor would induce
them to return. Eight respondents noted factors regarding practice
management, support personnel, facilities, and practice volume.
Town-gown relationships, time constraints, and support in terms
of time and money for research each were mentioned by one or two
respondents.
Most of the responses to the final item, "Please feel
free to elaborate on any of your responses or to add other comments," reiterated
concerns voiced in response to query 33. Three respondents reported
happiness with their new position. One respondent wrote that he
was applying for another full-time academic position because of
the changes that managed care had forced on private practice. Another responded: "Academic
orthopaedic surgery is becoming a stepping stone rather than a career.
As funds become scarce, the weaker chairmen see older, tenured faculty
as undesirable, since the same clinical income can be obtained (at
least in their minds) by fresh graduates. Most of the people going
into academics that I have talked to see it as a 2-4 year commitment
only and plan to move on to private practice. Since there is no
pressure for tenure, their research output is minimal, and they
work primarily as salaried clinicians who happen to have residents."
Results from the recently published index study covering the years
1959 through 19981 indicated that
70% of full-time academic orthopaedists remain in their
positions for at least ten years; 53%, for at least twenty years;
and 30%, for at least thirty years, with some variation
noted by decade. Therefore, any statement that the attrition rate
from academic orthopaedics is high or low is open to debate. When even
one full-time academic orthopaedist moves to private practice, however,
the tangible and intangible costs to the institution are considerable,
especially in times of diminishing resources.
Failure to obtain board certification was not a reason for leaving, as
93% of the respondents were board-certified at the time
of their departure to private practice. Similarly, all but four respondents
reported that they had left voluntarily, and "achieving
tenure" was rated the lowest of ten factors regarding the
decision to leave.
As seen in Table II and also as reflected in the responses
to the open-ended question, leadership problems at both the departmental
and the institutional level were the principal reason for leaving.
Other factors with average visual analog scores more than halfway along
the line extending from "no effect" to "critically
important" were level of financial autonomy, level of financial compensation,
and physical resources for practice. Moderately important factors
were resources for research, and patient volume and/or
mix; relatively unimportant factors were geographical location,
spouse’s career/concerns, and achieving tenure.
Taken together, these less important factors seem to indicate that
faculty members’ commitment to academic ideals was initially
high and that they did not view the academic Âposition as
a stepping stone to private practice. As might be expected, respondents
were less interested in research and teaching and more interested
in clinical practice on departure from their full-time academic
positions. Even so, the scores for commitment to clinical research
and teaching remained greater than halfway along the visual analog
scale ranging from "low" to "high," and the
score for commitment to administration remained statistically unchanged.
These findings also suggest that the respondents remained committed
to academic standards even as they entered private practice.
With a 69% response rate to the questionnaire and no
significant differences in several key measures between respondents
and nonrespondents, the data appear to be valid. There are, however, several
potential flaws in this study. Although a 69% response rate
is excellent for a mailed questionnaire, the potential for an unanticipated
bias exists. Also, departmental chairs and institutional deans were
not polled to obtain their point of view regarding the faculty members’ departure,
and the faculty members may have more easily recalled and identified
external causes for departure rather than personal shortcomings.
A literature search for articles on attrition from full-time
medical school academic positions did not reveal similar studies
of other specialties or of Âorthopaedics at other time
periods. This study therefore serves as a benchmark for future comparisons
within orthopaedics and with other specialties. Writing about the
turnover of Âacademic faculty members in geriatric and
general internal medicine, Applegate and Williams2,
in 1990, thought that their observations would be applicable to
most clinical academic disciplines. They stated that "Many junior
faculty are overburdened with clinical demands and do not have a
well-focuseÂd research agenda." The principal
reasons that they found for failure of academic survival were failure
to dÂefine goals, poor job selection and negotiation of
support, poor time management, inadequate understanding of requirements for
promotion, and lack of research Âfocus and productivity. All
of these factors, except tenure issues, may have had roles in the
career changes noted in our study. All of the factors that Applegate
and ÂWilliams mentioned would also be controllable to variable
degrees by effective departmental and institutional leadership.
Applegate and Williams concluded that "The availability
and Âselection of an appropriate mentor may be the most
crucial element for ultimate success."
Traditionally, orthopaedic chairpersons have been selected primarily
on the basis of their academic productivity and potential. Most
academic orthopaedists assume this leadership position without any
formal training or noteworthy experience in business-management areas
such as finance, personnel, or resources. Considering that orthopaedic
departments are multimillion-dollar enterprises involving a group
of highly intelligent and independent-Âminded people, it
should not be surprising that leadership issues were frequently
raised by the respondents in this study. It is logical to assume
that if a chairperson is ineffective in business management or is
preocÂcupied by his or her own academic career, the mentoring
of junior faculty members suffers. Demonstrated proficiency in basic
business skills should be a prerequisite for assuming departmental
leadership responsibilities.
Furthermore, orthopaedic chairpersons are typically appointed for
an indefinite period. Many nonmedical and some medical academic
departments rotate the chair leadership on a five-to-eight-year
basis. As with presidential leadership on a national level, one
has generally accomplished major goals, if they are achievable,
within such a time frame. In the discussion that this paper may
generate, consideration should be given to term limits on new chair
appointments.
Issues of faculty development and retention and size of full-time
faculties are likely to become acute as the role of academic centers
is redefined in the twenty-first century. In 1996, Korn3 observed: "Academic medicine is
entering an era of profound, unsettling change resulting not simply
from the drastic transformation of the health care marketplace but
more fundamentally from the chronic, growing gap between academic
medicine’s seemingly insatiable demand for total resources
and the supply of resources that society is willing to provide." Strong
departmental leadership and effective mentoring may help young orthopaedists
to develop and sustain meaningful academic careers and eventually
to provide strong leadership and mentoring themselves.
Note: The statistical analysis was graciously performed by Frederick
J. Dorey, PhD.
Meals RA; Bassewitz HL; and Dorey FJ: Academic longevity and attrition of full-time orthopaedic
faculty members. J Bone Joint Surg Am,2000.82: 1042-8, 821042Â
2000Â
[PubMed] Â
Applegate WB, and Williams ME: Career development in academic medicine. Am J Med,1990.88: 263-7, 88263Â
1990Â
[PubMed] Â
Korn D: Reengineering academic medical centers: reengineering
academic values. Acad Med,1996.71: 1033-43, 711033Â
1996Â
[PubMed] Â