What Can Be Done to Improve the Retention of Clinical Faculty?

Addressing Predictable Challenges of Career Building

With their multiple (and now often competing) missions and their convoluted and uncertain funding sources, AHCs are probably the most complex organizations in the world. In addition, given the range of both technical and political skills required, advancing in academic medicine has never been easy. With the increasing challenges of all roles and responsibilities within AHCs and the increasing competition for all sources of funding, however, building an academic career in medicine has never been more difficult. Clinical faculty face demands to see ever greater numbers of patients (with concomitant charting and administrative burdens). Academic activities (such as grant writing, preparing lectures and courses, writing articles, manuscript and grant reviewing, and mentoring) and other professional responsibilities (such as board recertification and professional society service) must be squeezed in between meetings and often urgent calls and e-mails. In order to procure protected time (although a highly respected AHC chief financial officer has said that the only protected time faculty will find from now on is in jail), clinical faculty seeking to contribute the scholarship necessary for promotion on most CE tracks must win a grant. Some evenings and weekends must, therefore, be dedicated to writing grants, intensely competing with colleagues who are also devoting their weekends to this activity. If they are successful, additional administrative responsibilities accrue and soon the work of competing for a renewal (usually an even smaller pot of money).

Probably even the most talented CE faculty find this continuous ramping up of both clinical demands and competition for grants challenging—not only because of the built-in expectation of personal overextension but, often more significantly, because they feel guilty for shortchanging their students, patients, and colleagues. As one CE faculty put it, she begins her day asking, “Who will I disappoint most today?”

Some faculty use whatever leverage they can to get the boss to pay more attention to them; some aggressively self-promote and take credit for others' work, and some work to procure a job offer from another institution so they can try negotiating a retention package. If they are successful, the resulting accomodation introduces inequities in salary and resources and penalizes those who are unsuited to this kind of gaming. In any case, the impact of such behaviors on the culture is uniformly negative.

Given the inevitability of the giant adding machine down the hall and the whatever-the-market-will-bear competition, what can AHCs do to retain valuable clinical faculty? AHCs can rarely promise more money or academic promotion to clinicians, but they can work more effectively with and support faculty along numerous other avenues.

• Most young clinicians are seeking a variety of ways to grow and make a difference and the possibility of integrating their personal and professional lives. ⁶ In recruiting faculty, department heads, faculty affairs deans, and human resources (HR) personnel need to strike a delicate balance with candidates, fairly representing institutional missions and service needs while simultaneously respecting the ideals and goals that young clinicians bring. Rather than taking advantage of their naivete, time spent exploring questions of fit and helping the candidate gain an accurate view of expectations is time very well spent. Although such conversations may strike AHC personnel as a kind of career coaching outside their purview, generational and environmental changes indicate a need for these individualized discussions.

These findings add weight to other sources of evidence that AHCs experience multiple benefits from investing in faculty career development programs ¹⁰ that support not only skill building of individual faculty but also relationship building among faculty across disciplines and, hence, a more relational culture. A sense of closeness with a colleague has been found to counterbalance the effects of a negative culture. ¹¹ Because women are at greater risk of feeling disconnected from the institution and seem to have a harder time tolerating the impossibility of meeting the expectations they encounter daily, it makes sense for AHCs to offer programs and opportunities that especially assist women and minorities to forge supportive relationships and to acquire career management skills.

Department heads are key to the success of all such activities; thus, AHCs should also be supporting chairs and chiefs in these directions and holding them responsibile for their faculty development and leadership practices. ¹²

Updating Faculty Policies

The finding by Speck et al. ⁴ that an extension of the probationary period reduced the risk of faculty departure by 64% also deserves attention. As the authors report, the school's promotion policies now make explicit if a candidate has taken an approved extension and state that the candidate's productivity should be evaluated as if the probationary period were of normal duration, making sure that the candidate is not penalized for taking advantage of the flexibility. I agree with the authors that these kinds of emendations are necessary for these hard-won policy changes to actually gain faculty acceptance and to have their intended impact.

Despite massive changes in generational characteristics ¹³ and other influences on how careers are built, much work remains in nudging anachronistic promotion and tenure structures from their traditionally rigid binary of up-or-out so that faculty do not have to choose between professional success and meeting responsibilities outside the workplace (now that so few have full-time support at home). A recent Association of American Medical Colleges (AAMC) study of U.S. medical school's faculty personnel policies found that only 14 U.S. schools had all three policies central to increased flexibility, that is, lengthened probationary period, clock stopping in the promotion process, and options for less-than-full-time for a limited period. ¹⁴ Such options for expanding and contracting work hours, especially in a field as demanding as medicine, are vital to making academe competitive with other career paths. Flexible options have other benefits as well. ¹⁵ For example, part-time practice has been shown to be satisfying not only for physicians but also for their patients. ¹⁶ Although flexibility may incur some up-front tradeoffs, these structural improvements are less expensive than rerecruiting and onboarding replacements, and they are likely to translate into a competitive advantage because flexible policies will attract and encourage the loyalty of individuals who have many decades of professional life ahead of them.

Conclusions

The findings of this study ⁴ shed light on the fact that even very skilled and committed faculty are struggling to stay afloat and on the downside of the revolving door approach to hiring them. Especially given predictably worsening shortages of faculty and of discretionary funds, preventing the attrition of junior faculty and doing what can be done to help them achieve their potential is surely a smart business strategy.

Speck et al. ⁴ also draw attention to the bigger question of the viability of CE tracks as they are typically configured. Is the dual expectation of clinical productivity and competitive grant funding sustainable? Excellent clinicians who are also productive scholars and skilled educators have been the foundation of academic medicine; the synergy they embody is precious. This model, however, is threatened by a perfect storm of the next generation's expectations about work hours, a physician and hence clinical faculty shortage, and increasing competition for shrinking funds and discretionary time. Expecting clinical faculty to work even harder is not the answer and is already backfiring. What are junior faculty telling us about what it takes to build a satisfying, resilient career? What would be the result of dialing back a bit on what is required for promotion on CE tracks? Rather than a threat to excellence, such reconsiderations may actually extend the life (and hence productivity) of faculty, reduce costs, and help to keep the “academic” in academic medicine.

In summary, unnecessary faculty turnover causes major disruptions and expenses. Thus, institutional efforts to prevent the loss of faculty save both intellectual and financial capital. Those departments and AHCs that offer a collegial work environment, skill development opportunities, and options for more personalized career paths will be increasingly able to recruit and retain the best faculty they can and hence gain a multidimensional competitive advantage.