PROCEEDINGS
OF THE 30TH BETHESDA CONFERENCE. THE FUTURE OF ACADEMIC
CARDIOLOGY. BETHESDA, MARYLAND, OCTOBER 26-27, 1998.
JACC Vol. 33, No. 5, April 1999:1091-1135
30th
Bethesda Conference:
The Future of Academic Cardiology*
Task
Force 4: Faculty
Joseph
S. Alpert, MD, FACC, Co-Chair,
Carl V. Leier, MD, FACC, Co-Chair
CHALLENGES
TO PROMOTION AND TENURE
During
the last two decades, academic health centers have become
increasingly dependent upon clinical activity for revenue.
In addition, competition for peer-reviewed research
grants has increased. These changes have led to fundamental
changes in faculty composition and activity.
Faculty
engaged in clinical activities are under increasing
pressure to achieve clinical productivity. Because peer-reviewed
research funding is increasingly competitive, such awards
are now limited mostly to applicants who spend at least
75% of their time on research.
Given
the current situation, it is not surprising that the
nation's academic health centers have struggled to confront
complex issues of faculty evaluation, recognition, promotion,
financial compensation and retention. The traditional
evaluation and promotion strategies of earlier times
are no longer applicable to the current needs of academic
health centers and the activity patterns of their faculty.
The incentives to forge a long-term academic career
have changed. Thus, there are a number of difficulties
in the evaluation, promotion and retention of faculty.
New
Promotion Tracks
In
response to the changing nature of the faculty, academic
health centers have modified their promotion tracks.
Details vary among institutions, but the general strategy
is as outlined below. In essence, the traditional tenure
promotion track has proved insufficient to cover the
new activity patterns of current faculty. The system
has been supplemented with additional tracks.
Investigator
track. This track, which has existed for decades,
predominantly recognizes research productivity as judged
by peer-reviewed grant funding and publications. For
the most part, faculty who engage in more than a token
amount of clinical activity are not able to achieve
the necessary research credentials to be competitive
in this track. Consequently, this track has often become
the "basic science" or bench research track.
However, at some institutions this track can include
a highly productive clinical investigator. Cardiologists
who predominantly perform research should be expected,
after a 3- to 5-year start-up period, to generate most
of their salary through research grants. The remaining
salary would come from endowment or institutional resources
or the income of his/her modest clinical activities.
Resources would generally be made available for space,
equipment, personnel and investigator salary support
over the first 3 to 5 years. The basic investigator
who is not able to achieve these financial guidelines
cannot expect to continue in the faculty ranks of most
divisions or must reduce research effort to the level
of research support.
In
addition to funding his/her own research program and
most of the salary stipend, the basic investigator is
expected to collaborate closely with the academic clinical
faculty of the division and other university faculty
to enhance the research prowess of the program and the
division, and to provide a research training program
for cardiology fellows, graduate students and postdoctoral
associates. The basic investigator, like the clinician,
must be supported for his/her teaching effort.
Clinician-scholar
(clinician-investigator) track. This track evolved
in the 1980s and currently has become the predominant
promotional track for clinical faculty. Individuals
on the clinician-scholar track are expected to be outstanding
clinicians who contribute heavily to the institution's
teaching activity. The clinical faculty member should
be expected to do more than see patients and/or do procedures.
He/she should participate in multicenter trials and
ideally, eventually direct or codirect one or more of
these, generate a modest number of clinical reports
and teach students, house staff and fellows during part
of his/her day-to-day clinical activities. These expectations
impart and justify the term "academician"
irrespective of whether he/she is on the tenure track.
The professional satisfaction of the teaching role and
study participation also serve to attract faculty members
to the division. These faculty members are typically
loyal to the academic mission, excellent teachers of
clinical and bedside cardiology, extremely hard working,
respected clinicians and superb role models. Most divisions
will fail to thrive clinically, investigatively, academically
and financially without many faculty members serving
in these clinical roles and without a large patient
population under its care.
Valid
and rigorous evaluation of performance on this track
has posed a complex challenge to institutions, since
it is often difficult to develop rigorous methodologies
to evaluate clinical and teaching performance. The number
of clinical faculty needed to develop a successful division
will vary widely depending on the location of the institution,
resources available, potential referral base, interaction
with referring physicians and local centers, Health
Maintenance Organization or managed care contracts (awarded
and under negotiation) and so forth. For most divisions,
the academic clinicians could constitute 50% or more
of the total faculty. For divisions that are community-based
and draw on practicing clinicians to cover the teaching
needs or the few divisions that are extremely well funded
for research, the central role and number of the geographic
full-time academic clinicians might be lower.
Clinician-educator
track. In response to the increased need for clinical
activity by fully affiliated faculty, some academic
health centers have developed a third promotion track.
The principal mission of faculty on this track is to
engage in clinical practice and teach. Responsibilities
for scholarship are subsidiary. Whereas this track enables
institutions to hire, promote and retain clinical faculty
who do not publish, the relationship of this track to
the clinician-educator track is often less clearly defined.
At times there is competition for referrals between
faculty on the two tracks.
Affiliated
clinical faculty. Traditionally, academic health
centers have had an abundance of affiliated clinical
faculty. These individuals are generally in private
practice and are not employed by the institution. They
may have limited teaching responsibilities and are not
subject to the appointment and promotion requirements
of the full-time faculty. The fraction of the institution's
clinical activity and teaching provided by these individuals
varies depending upon the overall organization of the
medical center but in general is not substantial. Criteria
differ among institutions for appointment and promotion
of affiliate faculty. Occasionally, long-term affiliate
faculty leave private practice and join one of the above-mentioned
academic tracks, thereby becoming employees of the academic
medical center.
Challenges
to Meeting Promotional Requirements for Fully Affiliated
Faculty
Requisites
to be a successful academic cardiologist. The traditional
successful academic cardiologist was said to be proficient
in three areas: research, clinical skill and teaching.
Each of these entities requires separate skills, and
there is incomplete overlap between them, that is, development
of successful research productivity does not necessarily
confer excellent clinical skills or teaching proficiency.
Success in the research arena, basic or clinical, requires
training, creativity and the application of a sufficient
fraction of the individual's time to generate data,
analyze it and prepare manuscripts reporting the results.
Success as a clinician requires sufficient experience
to acquire the requisite clinical acumen and skills,
an ongoing clinical practice and continuous self-education
to maintain and extend proficiency. Success as an educator
requires the motivation to teach, in-depth knowledge
of the subject and the acquisition of the necessary
skills to communicate concepts to students. Real success
in all three areas is probably no longer realistic;
even excellence in two areas is difficult to achieve.
Research
requirements. Successful research requires funding.
It is no longer possible to conduct important research
in one's spare time using borrowed facilities. Consequently,
it is necessary to secure funding to support both the
costs of the research and the faculty member's salary.
Securing research funding requires the development of
requisite credentials and the production of credible
proposals to funding organizations. Consequently, an
individual in the early stages of his or her career
must devote the majority of their time and effort to
acquire such skills and credentials. Such an effort
allocation is not consistent with the time needed to
develop and maintain top-flight clinical credentials.
Accordingly, individuals who seek successful careers
as investigators must devote the majority of their time
to that activity.
Clinical
demands. Individuals who pursue clinical career
tracks in cardiology must confront three axioms:
- Clinical
cardiology is sufficiently complex and demanding that
one cannot achieve and maintain proficiency without
practicing actively.
- The
salary support for academic clinicians is derived
almost exclusively from their clinical revenues.
- Clinical
cardiology practice is punctuated with frequent emergencies
which make it difficult to compartmentalize one's
time.
Consequently,
academic clinical cardiologists must engage in relatively
high volume clinical practice. Such activity patterns
tend to demand a large fraction of an individual's
time and may be difficult to differentiate from
the activity patterns of many clinicians in nonacademic
practice.
Faculty
assessment and performance improvement. Although
cardiology faculty members may initially be uncomfortable
with the concept of assessment of performance, formal
evaluation of all areas of the mission are becoming
more common. Such assessments can be used to recognize
clinical achievement with appropriate reward, and
to point out opportunities for improvement. A number
of clinical benchmarks can be employed in this analysis.
For example, the relative value units (RVUs) generated
by an academic cardiologist will approach those
of a practicing cardiologist with modifications
for teaching and research effort.
Research
metrics (grant dollars and publications) are more
standardized for the promotion process than are
those employed for clinical effort. However, evidence
of independent investigation is becoming less important
in the current era, with collaborative investigational
projects the commonest form of biomedical research.
Much work remains to be done with respect to evaluation
of educational performance, although standardized
student evaluations and quantitation of educational
time and effort are becoming more common. Service
to a variety of university, community and national
organizations must be recognized.
Such
formal evaluations can improve mentoring and lead
to valuable discussions of the individual faculty
member's goals and how these relate to those of
the department and of the institution.
Forces
acting on faculty.RESEARCH FACULTY.A
research faculty member's entire career depends
upon his/her research productivity. Such an individual's
performance evaluation will be heavily influenced
by research funding and publications. Consequently,
such an individual has little incentive to participate
in teaching activities or to develop teaching skills.
A research faculty member has two principal career
hurdles: to establish a successful program which
has consistent productivity and sustained funding;
and to maintain that output over a career. The latter
is perhaps the more daunting challenge since it
requires sustained creativity.
CLINICAL
FACULTY.
A faculty member in the clinician-educator track
must achieve clinical excellence and produce sufficient
scholarly output so that he/she can be distinguished
from a nonacademic clinician. Currently, clinician-educators
are subject to substantial clinical productivity
requirements. These demands reduce the time available
to engage in scholarly work. Thus, there are many
clinician-educators who are devoting virtually all
of their time and energy to clinical activity and
are not able to achieve requisite scholarly production.
Faculty
Development and Counseling
For
faculty to develop a long-term, successful and satisfying
career, considerable mentoring and faculty development
are essential. Many academic institutions lack effective
programs in this area. All too often, new faculty
are left on their own, floundering as they attempt
to develop their careers. In addition, some cardiology
faculty will require training in nonclinical areas
such as informatics, decision analysis, educational
theory, leadership and business management practices.
The latter two areas are particularly relevant for
divisional leaders.
Aligning
Faculty Incentives With Mission and Goals
Faculty
need to be organized and perform as a business unit,
with defined business lines (teaching, research,
patient care) integrated and managed to accomplish
objectives supporting the mission and vision of
the division. Faculty need to be intimately involved
in all aspects of divisional planning and decision
making.
Total
compensation including salary supplements or incentive
bonuses for faculty should reward productivity and
be aligned with what is of value to the division
and the institution. Incentive plans for highly
productive faculty should be based not only on financial
performance (i.e., total revenue generation minus
expenses), but on RVU[zzaq;37] generation with significant
credit given to evaluation and management RVUs.
Some institutions have introduced "multiplier"
factors, whereby new patient visits and new consultations
are assigned a higher value for incentive plan calculations
than the standard RVUs assigned to those Current
Procedural Terminology[zzaq;38] (CPT) codes. Other
creative approaches to motivate faculty performance
might include salary supplements for obtaining extramural
research funding or receiving teaching awards. Incentives
can also be created to attract and retain new and
current faculty. For example, the division could
create an equity fund with contributions made per
year of faculty service. This is comparable to approaches
undertaken in private practice groups where members
of the group buy into the practice. Such a plan
represents a cumulative investment by the faculty
member that can be withdrawn at retirement or when
the faculty member leaves the institution. Other
creative incentive packages should be developed
to motivate excellence in teaching and research.
Supplemental
Funding of Teaching and Research
Although
much of cardiology teaching occurs as part of day-to-day
clinical activity (e.g., ward rounds, reading echocardiograms),
dedicated time must often be set aside for the delivery
of more didactic education. The three- to five-year
start-up period for the new faculty member with
a primary focus on cardiovascular research is not
sufficient to generate an adequate income (clinical
or research) to support that salary line.
Funding
for these teaching and research activities remains
a challenge and a serious threat to the mission
and future of cardiology divisions. To date, these
monies have been largely obtained from divisional
clinical income. Clinical income has decreased to
the level where these monies are no longer adequate
or even available for teaching and research. Negotiating
a reduction in cardiology financial support rendered
to the departmental budget should be readdressed
for the purpose of redirecting these dollars to
the teaching and research mission of the cardiology
division. Other sources of funding must include
departmental and medical school teaching and start-up
funds. Adding release-time salary support to grants
(including industrial grants) should be encouraged.
Endowments need to be considered for ongoing funding
for teaching and research and are likely to become
the major solution in the future.
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