Abstract
Work-life balance is important to recruitment and retention of the younger generation of medical faculty, but medical school flexibility policies have not been fully effective. We have reported that our school’s policies are underutilized due to faculty concerns about looking uncommitted to career or team. Since policies include leaves and accommodations that reduce physical presence, faculty may fear “face-time bias,” which negatively affects evaluation of those not “seen” at work. Face-time bias is reported to negatively affect salary and career progress. We explored face-time bias on a leadership level and described development of compensation criteria intended to mitigate face-time bias, raise visibility, and reward commitment and contribution to team/group goals. Leaders from 6 partner departments participated in standardized interviews and group meetings. Ten compensation plans were analyzed, and published literature was reviewed. Leaders did not perceive face-time issues but saw team pressure and perception of availability as performance motivators. Compensation plans were multifactor productivity based with many quantifiable criteria; few addressed team contributions. Using these findings, novel compensation criteria were developed based on a published model to mitigate face-time bias associated with team perceptions. Criteria for organizational citizenship to raise visibility and reward group outcomes were included. We conclude that team pressure and perception of availability have the potential to lead to bias and may contribute to underuse of flexibility policies. Recognizing organizational citizenship and cooperative effort via specific criteria in a compensation plan may enhance a culture of flexibility. These novel criteria have been effective in one pilot department.
Introduction
The specialty of pathology faces considerable challenges in providing the pathologist workforce of the future. The Association of American Medical Colleges’ Specialty Data File for 2014 reported that pathology (anatomic and clinical combined) has had the greatest 5-year decrease in active practitioners (10.2%), the greatest decline in first-year residents (9.5%), and the highest percentage (60.7%) of active practitioners older than 55 years, among all the medical specialties. 1 Furthermore, the percentage of American medical graduates choosing a career in pathology has decreased from 2.3% in 2010 to 1.7% in 2015. 2
Fewer pathologists mean a shrinking recruitment pool for academic pathology. There are recruitment challenges in academic medical careers due to stagnant or decreases in research funding pay lines, the need to do more clinical work to generate income, and pressure to provide teaching that is often unfunded. A recent publication by Howell et al noted the strategic importance of recruiting and retaining the growing pool of female talent in pathology 3 since 54.0% of pathology residents are women. 1 Cultivating women’s careers in academia, however, means addressing additional challenges related to work and family. Compared to men, women faculty spend more time on child-raising and household activities, have fewer publications, slower self-perceived career progress, lower career satisfaction, and are less likely to achieve tenure. 4 –12 The National Academies’ landmark report “Beyond Bias and Barriers” highlighted career flexibility as a strategy to recruit and retain women in academic biomedical science. 13
There is growing recognition of the importance of family and work-life balance among the younger generation. 14 –23 Creating flexible work environments to support work-life balance and career satisfaction is an increasingly common strategy used by many industries to recruit and retain talent, especially women. Most medical schools, including our own, have adopted career flexibility policies to help recruit and retain the next generation of faculty. These policies typically include some combination of childbearing and family leaves, opportunities for part-time and remote work, and tenure clock extensions 24 –26 but are typically underutilized.
As part of a National Institutes of Health (NIH)-funded study on women’s careers in biomedical science, we surveyed our faculty and found considerable enthusiasm and anticipated need for career flexibility by both genders. Faculty also reported reluctance to use our school’s flexibility policies due to perceived barriers, most notably concern that using the policies would lead to perception of being less committed to career or a burden to colleagues/teammates. Women reported these barriers more than men. 27–28 We believe these barriers reflect face-time bias, a form of flexibility stigma and unconscious bias related to the amount of time one is observed in the workplace that can lead to quick and lasting impressions about commitment and other traits, adversely affecting perceptions of employees and influencing the performance appraisals of those utilizing flexibility options. 29 The Journal of Social Issues devoted a special issue to the flexibility stigma and published several studies demonstrating that professional women working flexibly are subjected to various forms of stigmatizing treatment, which can prompt women to suspend their careers, and that men using flexibility policies also experienced stigma, resulting in depressed earnings and limited career opportunities for both genders. 30 –33 Faculty members who use flexibility policies may therefore be paradoxically disadvantaging their career development, contrary to the institution’s intent and goals in providing these policies.
As the recipient of a 2012 Faculty Career Flexibility Innovation Award from the American Council on Education and the Alfred P. Sloan Foundation, 34 our focus has been to address face-time bias and flexibility stigma at the University of California, Davis School of Medicine (UCDSOM) by appropriately defining performance incentives and criteria within a faculty compensation plan. Compensation criteria are powerful vehicles communicating organizational values and priorities and greatly influence faculty attitudes, behavior, and institutional culture.
In this report, we describe our collaborative multispecialty approach exploring how face-time bias manifests itself on the department leadership level and how we used our findings to develop novel compensation plan criteria to mitigate face-time bias and bring visibility and reward to team-based contribution and citizenship. We believe that using compensation as a strategy will change behavior, mitigate face-time bias, minimize stigma and penalty, and create alignment with institutional values that will facilitate a culture of flexibility, better support faculty career satisfaction and retention, and achieve academic missions. We share the experience of UCDSOM’s Department of Pathology and Laboratory Medicine, which served as a development partner in this project and as a pilot department for implementation.
Methods
Two policies serve as a frame of reference for our work: (1) UCDSOM’s career flexibility policies and (2) University of California Health Science Compensation Plan (UCHSCP).
The UCDSOM’s flexible career policies are summarized in Table 1 and are posted on a dedicated page of the UCDSOM’s Web site. 26 Our school’s policies were standardized across all departments in 2004 and are designed to support faculty in all academic tracks (tenure track and nontenure tracks). These policies provide increased career flexibility through tenure clock extension around childbirth, adoption, and child rearing and provide for modified duties and part-time appointments.
Flexible Career Policies Involving Leaves and Reduced Duties.
The University of California Health Sciences Compensation Plan (UCDHSCP) is a University of California (UC) system-wide policy. 35 This policy defines 3 salary components: (1) a base salary scale reflecting academic rank as well as years within rank, which is identical to the salary scale applied to faculty in non-health science schools and colleges across the UC campuses; (2) a differential salary component, which is intended to make salaries competitive for academic health science professionals; and (3) an “incentive” or “bonus” salary component. The health science schools implement these based on locally defined criteria. At UCDSOM, a school-wide compensation plan template has been created, which includes customizable portions in which departments define their own criteria appropriate to their unique practices and strategic goals. In general, the practice at UC Davis Medical Center (UCDHS) is to benchmark faculty salaries (base + differential) against salaries reported for each specialty within the Western region by the Association of American Medical Colleges in their annual survey; however, faculty must meet the criteria within the plan in order to achieve benchmarked salary or an incentive/bonus.
For this project, we enlisted 6 clinical departments (including the Department of Pathology and Laboratory Medicine as well as departments from medical, surgical, and other hospital-based specialties) in order to explore faculty-reported barriers to using flexibility policies (perception of being less serious about career and burdening teammates) and how compensation plans may influence these perceptions. Department chairs and their chief administrative officers (CAOs) participated in structured interviews as well as in 2 follow-up group meetings. The interviews were conducted by at least 2 of the authors and consisted of 5 guiding questions that served as a starting point for discussion: (1) What are the chair’s priorities in creating the compensation plan, (2) What are the priorities of the faculty, (3) How are the priorities influenced by the need for flexibility and face time, (4) What don’t you want to change about face time in your department, and (5) Do you think it is important to have a baseline level of face time?
Department compensation plans were reviewed and analyzed by the study team for the following elements: (1) identification of one of the 5 compensation plan models described by Bhagwat et al (chief driven, tailored individual system, section based, clinical productivity based, or multifactor productivity based), (2) number of criteria with objective or measurable elements, (3) criteria requiring high visibility or face time (such as attendance criteria), and (4) criteria/requirement to meet a departmental value such as citizenship or other “higher objective.” 36 Elements 2 to 4 were derived from the business classic “The Folly of Rewarding A While Hoping for B,” which describes 3 factors that, when overemphasized, can “foul-up” reward structure: overemphasis on objective criteria, highly visible behaviors (ie, activities requiring a high level of face time), and those that may reward inefficiencies in pursuit of higher objectives. 37 Examples of elements 2 to 4 appear in Table 2.
Major Categories of Compensation Plan Metrics With Examples.
Published articles on best practices and experiences in medical faculty compensation plan were obtained via a PubMed search and reviewed and used as references for the development of a compensation plan toolkit. The department chairs and CAOs also served as design team partners in the toolkit development portion of this project.
Findings
Interviews With Department Leaders
Interviews revealed that all participating department chairs and CAOs recognize that their faculty want flexibility to pursue a variety of professional interests. Additionally, leaders from 3 departments recognized that their faculty also wanted flexibility to meet personal needs. In general, chairs and CAOs perceived little emphasis on face time in their current department culture or compensation plans, particularly in 2 large departments with geographically decentralized faculty. Several department chairs commented that availability was valued more highly than physical presence or attendance, both of which are forms of face time. Three departments noted that a high value on individual career flexibility by their faculty members has overshadowed the need for faculty to contribute to group goals, creating issues related to clinical productivity, patient access to clinical services, and educational issues. Only 3 departments had a meeting attendance requirement to assure a critical mass and energy in teaching conferences and other meetings. The other 3 departments felt that face time was a nonissue since desired outcomes were achieved without this requirement due to peer pressure and team culture.
Despite these general views, chairs from all 6 departments studied felt that there was a general negative perception by colleagues and house staff when a faculty member was not seen. Terms such as “lack of citizenship” and “not doing one’s job” were used to describe faculty who were not visibly present at work as much as expected. Further, one department chair acknowledged that he or she perceived those taking leave as “less driven” than those who did not. We take these comments to indicate that there is, indeed, an “unconscious” face-time bias since these findings are consistent with what researchers have reported previously as general evidence of face-time bias. 29
Interviews also demonstrated that all department leaders sought to incentivize, reward, and grow clinical productivity, educational activities, research, and teamwork via their compensation plans. Chairs noted that they felt challenged to find an appropriate balance between rewarding individual performance, versus organizational citizenship, and team-based performance. Transparency in how compensation is determined was seen as a priority by chairs; they also believed that this was a priority among their faculty as well. Comparison of individual faculty members’ performance to their peers (ie, internal peer pressure) was used as a motivator in 2 departments, adding elements of competition and public scrutiny by peers. One department chair noted that adding internal competition and peer pressure changed their culture and led to some unintended consequences, such as departure of faculty who did not feel aligned with these new values.
Analysis of Criteria Within Department Compensation Plans
Several general models exist to categorize incentive plans. 36 Analysis of a total of 10 compensation plans from the 6 partner departments (including 4 plans from 4 divisions of 1 department) showed that the multifactor productivity-based model (which included criteria for all the academic missions) was predominant and was used by all the departments to determine a faculty member’s main salary. Additionally, 6 of the 10 departments/divisions used this model for their bonus plan. The other 4 departments used a clinical productivity model based on excess income for their bonus plans.
Quantifiable criteria were a strong feature in all the department compensations plans and were used to define main salary (ie, university base salary + differential salary for physicians) and bonus pay. Examples of quantitative criteria included individual revenue over expense, relative value units (RVUs) generated for clinical service, clinical hours or number of service rotations, numbers of lectures or teaching activities, publications, grants or grant dollars, and numbers of committees and editorial boards. One department places a very strong emphasis on quantifiable criteria and has published a description of their compensation plan and successful experience. 38,39 Tables 3 and 4 summarize the number of quantifiable criteria present in each of the categories of criteria analyzed in the department compensation plans. The department compensation plans overall averaged 6 quantifiable criteria in the compensation plan sections that defined a faculty member’s main salary and incentive/bonus salary. Several departments had 9 or 10 criteria in each category of criteria analyzed, and 1 had 14. Attendance criteria for conferences and departmental meeting, a measure of face time, were present in 4 of the 6 departments and most commonly appeared in the bonus sections of the plan. Efficiency measures were rare, appearing in plans in only 3 departments, and consisted of measures of time to completion of clinical study reports. In general, departments that were decentralized with fewer opportunities for faculty to be seen by coworkers measured many more quantifiable variables in their compensation plan.
Number of Components in Department Compensation Plans Used to Determine Main Salary.
Number of Components in Department Compensation Plans Used to Determine Incentive/Bonus Pay.
Criteria that emphasized a departmental or group objective, such as serving on national committee or as a society officer that helped to elevate the stature of the department or participation in peer-review activities to maintain quality, were commonly used to determine main salary. An average of 6 criteria of this type were noted in compensation plans reviewed. Only half of the compensation plans included this type of criteria in the bonus portion of the plan.
Criteria to Mitigate Face-Time Bias and Flexibility Stigma and a Compensation Plan Toolkit
The findings from department interviews and from the analyses of the compensation plans, along with recommendations from the literature, were used to develop suggested criteria for organizational citizenship and team contributions (Table 4), which were derived from a published model. 40 These metrics are intended to minimize the effects of unconscious biases related to the decreased visibility that a faculty member experiences when using flexible career policies, including leaves, alternate work schedules, or alternate work sites, by enhancing visibility and awareness of contributions and incentivizing behaviors and caring related to group goals. For easy reference and access by departments, these criteria were placed in a Web-based compensation plan toolkit linked from UCDSOM’s Academic Personnel Web site 41 and appear under the section “Metrics for Performance.” Although not detailed in this report, the toolkit also includes suggested metrics for all aspects of compensation, including general models for compensation plans, performance metrics for each academic mission (clinical service, research, and education), and a section on unintended consequences. 41 This toolkit is frequently used by departments and the school’s Compensation Advisory Committee, a committee of faculty peers who reviews, approves, and advises departments on their compensation plan. The toolkit components are modular and flexible and can be assembled in a way that meets the compensation goals of each department.
Pilot Department Outcomes
The UCDSOM’s Department of Pathology and Laboratory Medicine’s Faculty Advisory Committee on Compensation has incorporated some of the strategies for organizational citizenship and team contributions to mitigate face-time bias (summarized in Table 5) into the department’s compensation plan, including metrics associated with “Events,” the first category in that table. The department’s plan requires 50% annual attendance at a limited number of key department events, which are intended to minimize the need for faculty to be ever present and always available. The events chosen are largely focused on education and are considered significant events where faculty presence signals commitment to this part of the department’s mission, such as grand rounds, resident presentations, and journal clubs. In the 3 years since this requirement has been implemented, faculty attendance at these events has been strong and even increased, and resident evaluations of faculty commitment and interest in education have also risen, confirming that incentivizing face time at the right times allows the faculty to visibly demonstrate their commitment to the educational mission without overburdening their time commitment. More recent additions to the pathology and laboratory medicine compensation plan include metrics in the “Conscientiousness and Helping,” category of Table 2, for assuming extra duties due to changing circumstances and helping a colleague who has fallen behind in his or her work. These criteria have been added to emphasize that contributions to the group or team are just as important as meeting traditional metrics for individual accomplishments, such as number of publications or lectures, or RVUs generated, which are long-standing criteria in the department’s compensation plan. Our school’s Compensation Advisory Committee has lauded the department’s compensation plan as excellent and thorough.
Example Metrics for Rewarding Organizational Citizenship and Team Contributions to Mitigate Face-Time Bias.
Discussion
Face-time bias exists within department compensation plans in our school, despite considerable effort by chairs to create nonarbitrary and transparent methods for determining faculty salaries. Four plans had attendance requirements without defined roles or involvement in these meetings, and several plans included vague “citizenship” requirements. This requirement in the salary process for visibility and physical presence without associated performance outcomes is indicative of face-time bias, as defined in the literature. 29
Another indicator of face-time bias is the finding that all of the department leaders who we interviewed noted general negative perception by colleagues, house staff, and themselves when a faculty member is not seen. Our interviews highlighted an emphasis on team culture, peer pressure, and availability, each of these contains the potential for face-time bias or stigmatization leading to a negative effect on faculty evaluation and salary. A faculty member who uses a flexible work schedule, takes a family leave, or uses technology for distance work such as telemedicine or the electronic health record inevitably reduces his or her face time with other team members. This reduction in face time may strongly influence how a faculty member is perceived by peers and colleagues. Even if the faculty member performs excellently on assignments, others may be unaware since this faculty member and his/her work are less visible. This faculty member may therefore be perceived as less available, less engaged, less productive, less committed to career, and less valuable as a team member. This may in turn be reflected in that faculty member’s compensation. Furthermore, when a faculty member uses a flexibility policy with a leave or reduced hours, there is an extra burden on the team, which may lead to unfavorable feelings among teammates toward the faculty member. Indeed, our faculty surveys showed that approximately 20% to 30% of men and women of all generations chose not to use flexibility policies due to concerns about being perceived as overburdening colleagues. 28 These findings strongly suggest that a negative perception regarding a faculty member’s organizational citizenship and commitment to the team can influence an individual’s use of flexibility policies and trump a culture of flexibility. Metrics within a compensation plan that reward others for taking on the burden of extra work or contributing to the team can help mitigate negative perceptions toward those using flexibility policies.
Interestingly, criteria that emphasize organizational or team contribution were rare within the compensation plans that we examined, despite many publications that have emphasized the importance of objective and measurable criteria in compensation plans for academic medical practices. 42 –48 We see this gap as an opportunity to minimize face-time bias and stigma. Van Dyne et al present a model of work practices designed to promote flexible work arrangements by raising the visibility of an individual’s contributions to organizational citizenship and team-based work. 40 Using their model, we have created proposed metrics appropriate to a medical faculty compensation plan that are specifically intended to mitigate the adverse perceptions associated with face-time bias by better measuring organizational citizenship and team contributions. Table 4 describes these metrics and highlights the advantages these provide pertinent to career flexibility. We believe that such performance metrics within a compensation plan will allow faculty members using career flexibility policies to maintain visibility and facilitates recognition and appreciation of their contributions by their colleague and teammates. In our review of the literature, we found no other published descriptions of compensation plans that addressed organizational citizenship and teamwork in this depth and detail nor did we find considerations of the potential effects on a flexible work culture. The organizational citizenship metrics presented in Table 2 are included in the online compensation plan toolkit that we created to aid departments with guidance from published models, outcomes, and experiences.
Our compensation plan toolkit and the metrics for organizational citizenship that promote flexibility have been well received by our partner departments and our school’s Compensation Advisory Committee, which reviews, approves, and provides advice on department compensation plans. We credit our collaborative design process for the excellent response we have received on the toolkit and metrics. The Department of Pathology and Laboratory Medicine’s experience has been positive. By implementing these criteria related to organizational citizenship, the department seeks to increase caring and participation in department activities, incentivize behaviors related to the group, increase workplace flexibility since these provide more time and visibility for off-site work, and ultimately improve the departmental culture.
Limitations to our project include the fact that only a small number of departments at a single school of medicine were involved; however, we included 3 of the largest departments in our school. The literature clearly demonstrates that the problems we have sought to address, including addressing bias toward flexibility and finding effective compensation incentives, are universal challenges spanning departments and schools nationally. We recognize that only one department of pathology and laboratory medicine was involved and that different departments and schools have their unique local needs as well. A collaborative design process such as ours that actively involves stakeholders and utilizes guiding questions can help address local needs and allow each institution to customize a toolkit as a more tailored resource. We also recognize that our interview process only addressed the views of department leaders, which may not be a full view of attitudes and awareness toward face-time bias and the compensation process. Although faculty was not directly interviewed for this study, our previous published surveys that inspired this project have provided much insight into faculty views on flexibility and bias and were considered in the course of our work. 27,28
Another limitation is the absence of outcomes measures to evaluate whether the compensation criteria proposed effectively influence flexibility, reduce stigma and bias, and impact faculty careers. Many years may be required to assess outcomes since career paths and promotion intervals span multiple years and because many flexibility policies, such as childbearing leave, tenure clock extension, or family leaves, are needed infrequently and by a minority of faculty. Unintended consequences are also an outcome worth exploring as our approaches are implemented. This includes a “sorting effect” in which certain types of faculty members are attracted to or retained in a department or school as a result of the activities or behaviors that are rewarded. On the flip side, some faculty members may be pushed out. Sorting effects can change the work culture of departments and could potentially affect diversity as well since gender, race/ethnic, and cultural background may or may not align with the work culture of a department. Our toolkit includes a section titled “The Minefield of Unintended Consequences” in order to share these potential pitfalls with department leaders. 41
Faculty compensation is just one component of the reward process at a school of medicine. Academic advancement is another significant form of faculty recognition and reward, which can be potentially biased by perceptions that those working flexibly are less serious about their career or a burden to their colleagues. Our project did not address stigma and face-time bias in academic advancement, and this should also be considered in future work.
In conclusion, we have demonstrated how face-time bias and flexibility stigma can manifest at the department leadership level, particularly related to perceptions of availability and contributions to group or team, and how this might affect a department or school’s culture of flexibility. We suggest mitigating face-time bias by including metrics for compensation that focus on organizational citizenship to highlight and reward contributions to the team and for contributing to organizational goals. We share novel, collaboratively developed metrics for organizational citizenship, which we have made available through a Web-based institutional compensation plan toolkit that serves as a resource for others seeking to address similar issues. It is our strong belief that addressing face time and flexibility within the context of the compensation plan will facilitate a culture of flexibility, improve work-life balance and use of flexibility policies, and enhance team-based organizational citizenship to meet departmental missions and strategic goals. We believe that a healthy culture of flexibility is important for recruitment and retention of outstanding talent in all specialties within academic medicine, including pathology and laboratory medicine that is facing major workforce challenges. We also believe that a focus on minimizing face-time bias will position a department effectively for a future with less pathologist colocation and visibility due to the trend for development of regional networks anchored by a tertiary care academic health center with services delivered remotely via technology. We therefore encourage other departments and institutions to consider similar approaches and metrics that will allow physician contributions to be visible and valued no matter where work is done, minimizing face-time bias and flexibility stigma and increasing faculty satisfaction.
Footnotes
Acknowledgments
The authors wish to thank the following individuals for their participation and contribution to this project: Department Chairs Timothy Albertson, Raymond Dougherty, MD, Diana Farmer, MD, Robert Hales, MD, Nathan Kuppermann, MD; Department Chief Administrative Officers Ann Marie Boylan, Catherine Diaz-Khansefid, Nancy DeHerrera, Fatima Mohamud, Sharon Schmitt, Narriman Shahrokh, Benson Wong, Jennifer Wyatt; Chair of the Compensation Advisory Committee Colleen Clancy PhD; Associate Dean for Academic Personnel Edward Callahan.
Authors’ Note
The Institutional Review Board of the University of California, Davis approved this study as Protocol 305336-1.
Declaration of Conflicting Interests
The author(s) declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported in part by an Innovation Award for Medical School Faculty Career Flexibility from the Alfred P. Sloan Foundation and the American Council on Education, NIH award GM 088336 in partnership with the Office of Women’s Health Research (OWHR) with the goal of supporting “Research on Causal Factors and Interventions that Promote and Support the Careers of Women in Biomedical and Behavioral Science and Engineering,” and the Frances Lazda Endowment in Women’s Cardiovascular Medicine to A.C.V.