The mission of a traditional academic medical center with a medical school
typically includes excellent patient care, education of future physicians, and
the creation of new medical knowledge. In the last twenty-five years, as
academic medical centers rapidly expanded their clinical services, they began
to hire more full-time clinician educators to meet the demands for clinical
services and the education of future physicians.
When I started my medical career, traditional academic medical centers
hired a small cadre of physicians who were full-time faculty, who saw patients
for two half-days per week and/or operated one or two days a week, who
supervised inpatient patient care, and who provided education of medical
students and residents. As the competition for research funding intensified in
the last few decades, many of these faculty members devoted even more time to
research and restricted their already limited activities in clinical care and
education. Academic physicians engaged in the traditional triad have rapidly
disappeared, especially in tenure tracks. In academic medicine, the research
portion still predominates in the reward and promotion systems of traditional
academic medical centers. The emphasis on research as the basis for the
promotion of clinician scientists and tenured faculty has left the clinical
care and education to clinician educators. Most clinician educators,
especially surgeons, spend 85% to 90% of their time caring for patients and
teaching residents and medical students. Clinician educators, while excelling
at teaching and clinical care, now have little time to conduct any type of
research.
In the last two decades, many institutions have established new criteria
and/or tracks for the promotion of clinician educators. This was in response
to the growing need to attract, retain, and recognize faculty members who
devote their entire energy to clinical care and teaching. Almost always, these
new schemes for reward, promotion, and tracking do not offer the possibility
of tenure because of the reluctance of academic institutions to make long-term
commitments to faculty members who are primarily clinicians. This is
especially true for proceduralists, who have high incomes compared with most
tenured faculty. As a result, two-tiered or possibly three-tiered systems have
evolved. Tenure is available only to research-oriented faculty members.
Guidelines for the promotion of clinician educators usually involve an
assessment of their national reputation. Although research productivity, as
exemplified by grants or publications, is not required, it is very difficult
to acquire a national reputation without a significant number of clinical
publications and presentations at national meetings. Those with subspecialty
interests, such as orthopaedic surgeons, can develop national reputations
through making podium presentations, writing book chapters, and conducting
small, clinically based studies in their subspecialty fields. These activities
usually present level-III, IV, or V evidence.
Additional effort by clinician educators, as institutional citizens and in
administration, is finally being recognized. Clinician educators, besides
spending virtually all of their time providing clinical care and teaching, are
being asked to become leaders on hospital and university committees and in
other forms of administration. These types of activities often have little or
no recognition in the promotion process and certainly do not provide national
recognition. Thus, evaluating accomplishments for clinician educators
continues to be a challenge for traditional academic medical centers. There
are few valid and reliable measurement tools, so the evaluation of clinical
excellence is very problematic. Promotion and tenure committees seldom use
measurements of clinical productivity and excellence, such as the number of
patients seen, referrals from regional colleagues, and satisfaction ratings by
patients and colleagues. The only feasible types of scholarship for clinician
educators are writing book chapters and review articles that assess diagnosis
and treatment and examine low-level evidence-based theories drawn from their
clinical practice.
From my perspective, the requirement for a national reputation should be
ameliorated for the clinician educator to include yardsticks such as regional
referral reputation, clinical activity, institutional teaching, and
institutional and administrative activities. In addition to having a robust
clinical and/or surgical practice, the requirement to write articles that are
published in peer-reviewed journals should be expanded to include review
articles and patient education materials. However, there should be no mistake
that excellence in teaching is still undervalued and is still not the primary
mission of most traditional academic medical centers, particularly at
institutions whose deans and chairs measure success according to the ranking
of the medical center in terms of research funding.
In retrospect, my career paralleled these changes. When I came to the
University of Chicago, there was the single-track system of a traditional
academic medical center with a medical school. I arrived in 1975 as an
assistant professor and rapidly became an associate professor with tenure in
1979 and a full professor with tenure in 1983. It became apparent in the
mid-1980s that the University was unable to keep this traditional system.
Instead, the unified tenure system was divided into three full-time tracks.
One is a tenure track. The second is now called the clinician-scholar
(clinician-scientist) track, and the last is a clinician-educator track. At
this time, more than half of all of the faculty at the University of Chicago
are clinician educators. Interestingly enough, clinician educators are not
full-time faculty in the University and cannot have membership in the
University Senate, but they are members of the Biologic Sciences Division.
Thus, they are, in some sense, still second tier.
Three recent events have increased the value of the clinician educator at
the University of Chicago and probably should be implemented at other
traditional academic medical centers. (1) Wisely, the new Dean of the Biologic
Sciences Division, who is a scientist, was able to convince the University to
drop the word "clinical" from the title of full-time clinician
educator. This gave a very important subliminal message to the faculty and the
external world that all full-time faculty members at least have the same
titles. (2) The promotion process was redesigned and facilitated to make the
process less contentious, with clinical productivity being valued. (3) Most
importantly, there have been some appointments of clinician educators to key
leadership positions. The new Dean of Medical Education, who is responsible
for the medical school, is a clinician educator. She was the Program Director
of the Internal Medicine Residency Program. Likewise, another clinician
educator is in charge of the entire medical school curriculum. This is quite a
change from our traditional past. Clinician educators are also becoming
division chiefs in our traditional academic medical departments, and they are
called upon to make crucial institutional decisions.
As I look at my curriculum vitae, if I had started my career today and was
kept to the time line of promotions, I would not have even a remote chance of
becoming tenured, but I could expect to be promoted as a clinician educator in
this new academic medical paradigm. I hope that others in positions of
leadership in academic orthopaedics can benefit from our recent positive
experiences at the University of Chicago.