Leaders’ Perspectives on Resources for Academic Success: Defining Clinical Effort, Academic Time, and Faculty Support

Abstract

Introduction

For academic promotion, clinical faculty are expected to excel in clinical care, teaching, and scholarship. Ensuring adequate protected time and resources to engage in scholarly work in the face of competing clinical responsibilities is critical. The authors examined academic leaders’ perspectives across affiliate hospitals of a large medical school regarding the definition of clinical full-time effort and academic time, best practices to enable academic success, and barriers to faculty advancement.

Methods

Open-ended, semistructured, individual interviews were conducted with a purposive sample of clinical department and division heads. Interview data were examined to illuminate the range and commonalities in practices and to identify successful approaches.

Results

Interviews were conducted with 17 academic leaders across 6 affiliate hospitals. There was considerable variability in clinical full-time effort definition. “Academic time,” more accurately characterized as “nonclinical time,” was typically 1 day a week for nonshift specialties and mostly used for administrative work or completing clinical documentation. Certain departments were more explicit in designating and protecting time for academic pursuits; some had invested resources in intensive programs for academic advancement with built-in expectations for accountability. The impact of documentation burden was considerable in certain departments.

Discussion and Conclusion

Marked variability exists in time allocations for clinical and academic work, as well as in resources for academic success. This supports the potential value of establishing standards for defining and protecting academic time, motivating clinical faculty to engage in academic work, and building accountability expectations. Sharing best practices and setting standards may enhance academic advancement. Strategies to reduce documentation burden may enhance wellness.

Introduction

Academic promotion in most medical schools requires evidence of broad-based impact, manifested by a body of scholarship and reputation that extends beyond the walls of the school.¹ These goals can be particularly challenging for full-time clinicians given the demands of clinical work, the need to meet work relative value units (wRVUs) targets, teaching expectations, and administrative responsibilities^2–4 while balancing responsibilities and goals associated with their personal lives.⁴

Clinical faculty report spending 70% to 75% of their time on clinical activities and only 25% to 30% on nonclinical activities, particularly at entry-level academic ranks (eg, instructors or assistant professors).⁴ As a consequence, large numbers of superb clinical faculty, many of whom serve in key teacher–educator roles in outpatient clinics and on inpatient wards, may continue at these ranks for prolonged periods, with few eventually ascending to the higher ranks of associate or full professor.^1,5 Analysis of rates of promotion within 10 years using the Association of American Medical Colleges faculty roster ranged from 27% to 39% for assistant to associate professor MD faculty in clinical departments contrasted with a range of 42% to 55% for PhD faculty in basic science departments. For promotion from associate to full professor, 37% to 48% of MD faculty in clinical departments were promoted as compared to 38% to 54% of PhD faculty in basic science departments.⁵ This differential rate of promotion has been associated with whether or not faculty feel undervalued and disenfranchised.^4,6,7 In fact, one survey indicated that compared to basic science researchers in that medical school, academic clinicians had an 85% lower odds of being at a higher rank and a 90% lower odds (adjusted) of satisfaction with academic advancement.⁸ In additon, Nassar et al suggest that role conflict and role ambiguity may develop when nonclinical responsibilities (education, research, and administration) must be balanced against regular clinical responsibilities, particularly when time and resource allocation for some of these activities is uncertain or insufficient.⁴ Role conflict and ambiguity in certain settings has also been connected to burnout.^4,9,10 Eventually, faculty disenfranchisement and burnout can result in greater attrition, with increasing numbers of the clinical workforce leaving academic medicine.^11–13 With respect to protected time, while medical school-based programs provide more time for academic work than community-based medical school-affiliated programs, this is still far from optimal,^8,14–17 and unmet expectations of protected time have been associated with an intent to leave academic medicine.^13,18

Importantly, department chairs and division heads are at risk of being unaware of best practices in other institutions that could be adopted (or adapted) to address barriers to faculty advancement. Furthermore, a better understanding of the diversity of definitions of clinical and academic time and barriers to advancement could direct medical school leadership toward the necessary steps to both enhance transparency and provide faculty with protected time adequate to their career development goals, as well as departmental needs. The objectives of this study were to collect and examine exploratory data from a sample of academic leaders across Harvard Medical School (HMS) affiliate hospitals regarding 1) their definition of a clinical full-time effort (CFTE) and academic time (to explore the range of definitions across clinical fields and affiliates to shed light on how expectations and resources for clinical faculty vary), 2) best practices being implemented to enable clinical faculty to succeed academically, and 3) barriers to faculty advancement.

Methods

HMS is the largest medical school in the United States; though all HMS faculty receive their academic appointment through Harvard University, the majority of the approximately 12,000 HMS-appointed faculty are employed by 15 affiliated academic medical centers (AMCs) or institutes that determine individual job descriptions and compensation. At the time of data collection, HMS faculty engaged in clinical practice could be promoted within 1 of 3 Areas of Excellence, specifically Investigation, Teaching and Educational Leadership, and Clinical Expertise and Innovation.¹⁹ These pathways to promotion at HMS require scholarship, demonstration of impact, and reputation. Clinical Expertise and Innovation is often the best fit for those who spend the majority of their time in clinical care. The metrics are available at https://facultyhandbook.hms.harvard.edu/6crit-appt-promo/.

One author (MM) conducted semistructured interviews with a purposive sampling of department chairs or division heads selected by 3 authors (GCH, AEB, CKB) to include a subset of nonprocedural (medicine, pediatrics, psychiatry), procedural (surgery, ophthalmology), shift (emergency medicine and hospital medicine), and also nonpatient-facing (radiology) specialties across the 6 largest HMS affiliate hospitals. These hospitals included Massachusetts General Hospital, Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center, Boston Children’s Hospital, Massachusetts Eye and Ear Infirmary, and McLean Hospital. The protocol was approved by the Mass General Brigham Institutional Review Board, and the project was conducted under the guidance of the HMS Office for Faculty Affairs and Office for Clinical and Academic Affairs.

Table 1 displays the interview guide used in the present study, including questions collaboratively developed and iteratively revised among authors, taking into account the research questions being addressed and the nature of the specialty (procedural or nonprocedural; shift or nonshift; patient-facing or nonpatient-facing). Individual interviews took place in a single session and lasted between 30 and 60 minutes. In lieu of recording the interviews, the interviewer took detailed notes in real time for subsequent data analysis. A single author (MM) conducted a simple content analysis of the interview notes, collating and categorizing data based on themes that the interview questions were structured to elicit, and by specialty and institution. The interview notes were available to all coauthors. These themes included clinical field specific definitions of a CFTE and academic time (to determine how this was locally configured and operationalized), best practices to enable academic success, and barriers to faculty advancement. All authors discussed the interpretation of the interview data in detail.

Table 1:

Interview guide

All chairs	How does your department define clinical faculty? How do people spend the rest of their time?
Chairs of medicine and pediatrics	How does your department define 1 CFTE for faculty in the following categories? Predominantly outpatient with few or no procedures (eg, primary care, endocrinology, infectious diseases) Predominantly inpatient (eg, hospitalists) Procedural (eg, cardiology, gastroenterology, pulmonology)
Chairs of psychiatry, surgery, radiology, emergency medicine, and ophthalmology	How does your department define 1 CFTE?
All chairs	Does your department include academic time or an academic day for clinical faculty?
	How is academic time defined in your department and does this include administrative time? What is the intended use of an academic day (academic or administrative)?
	How do you (as the chair) perceive academic engagement in your department?
	How does your department operationalize and support academic time?
	What resources do you believe are necessary for the academic advancement of your clinical faculty?
	Which of the following resources are available to your clinical faculty? Formal mentorship program Sponsorship (sponsors have the position and authority to advocate publicly for advancement of nascent talent, including women) Professional coaching Professional funds (eg, to travel to national-level meetings in your specialty)
	What is your impression about the time your clinical faculty are spending on your electronic medical record outside of office hours? Do you have a way to quantify this?
	How is this impacting faculty? Are faculty in your department leaving academia because of documentation burden?
	Where are your clinical faculty in the context of how they envisioned their careers?
	Do your faculty feel disenfranchised or supported? The signal from our surveys is that many faculty feel disenfranchised—Is this something that you have perceived in your faculty?
	Do you have additional thoughts to share regarding academic advancement of clinical faculty?
Chairs of psychiatry, emergency medicine, radiology, and ophthalmologya	How are decisions made regarding clinical faculty attendance at national meetings?
	How many national conferences do your clinical faculty typically attend per year?
	How often do you typically meet with your clinical faculty? Instructors Assistant professors Associate professors
Chairs of surgery	What proportion of your faculty have blocked time for surgery (often a reason for more junior faculty to feel frustrated)?

^aThese questions were not asked of chairs of very large departments, such as medicine, pediatrics, and surgery, but were asked of the chiefs of hospital medicine and primary care within medicine and pediatrics.

CFTE, clinical full-time effort.

Results

Definition of CFTE

Over a period of 3 months, 17 department chairs or division heads were interviewed by 1 author (MM). The clinical specialties included were emergency medicine, medicine, ophthalmology, pediatrics, psychiatry, radiology, and surgery, and the number of respondents representing each specialty ranged from 1 to 3. Chiefs of primary care and hospital medicine were also interviewed given the size of those divisions in the department of medicine. Medicine, pediatrics, and psychiatry represented nonprocedural, nonshift, patient-facing specialties; surgery and ophthalmology, procedural specialties; emergency medicine and hospital medicine, shift specialties; and radiology, a nonpatient-facing specialty (which also has a procedural component). Five of the leaders were women (from the departments/divisions of medicine, primary care, hospital medicine, psychiatry, and ophthalmology). None of the leaders in this sample were underrepresented in medicine.

There was considerable variability in the definition of a CFTE across clinical specialties (Table 2). Reported factors that influenced this determination included intensity of work, divisional or departmental structure, and finances. Chairs acknowledged that few academic physicians in the departments of internal medicine and pediatrics (particularly in nonprocedural specialties) were able to engage in 8 full clinical sessions a week (each clinical session being 4 hours) given the documentation burden and the need to follow through with tests resulting after patient appointments.

Table 2:

Definition of a clinical full-time effort

Specialty	Definition of 1 CFTE
Nonshift specialties
Adult medicine and pediatrics
Primary care medicine and pediatrics	8 clinical sessions/wk
Procedural subspecialties (eg, cardiology, gastroenterology, and pulmonology)	5–8 clinical sessions/wk
Nonprocedural subspecialties (eg, endocrinology, genetics, nephrology, infectious diseases)	5–8 clinical sessions/wk
Radiology, surgery, ophthalmology	4 full clinical d/wk
Ambulatory psychiatry	28–32 h of direct patient contact
Shift-based specialties
Hospital medicine
Adult medicine	180–182 daytime 12-h shifts/y at academic sites (with variability across the 2 affiliates that were interviewed), and 200 daytime shifts/y at community-based sites affiliated with primary AMCs For nocturnists, a CFTE represented 144 nighttime shifts/y; not all affiliate hospitals provided hospitalist services at community sites
Pediatrics
Affiliate 1	120 weekday shifts (~10–12 h/shift, no set hours) and 12 weekends
Affiliate 2	126 8-h daytime shifts/y (with additional time spent prerounding and postshift for work completion) and 12 nighttime shifts (15 h/shift)
Emergency medicine
Affiliate 1	Academic physicians: 1200 clinical h/y (8–9 h/shift, yielding a maximum of 150 shifts/y) Nonfaculty (community-based) physicians: 1500–1600 clinical h/y Minimum of 0.4 CFTE required for faculty who were exclusively clinical
Affiliate 2	“Academic-heavy” track: 20 h/wk of clinical work (8–9 h/shift, or 6–10 h of urgent care shifts) “Academic-light” track: 20–32 h/wk “Community” track (physicians without academic appointments): 32 h/wk

AMC, academic medical center; CFTE, clinical full-time effort.

For shift-based specialties (ie, hospital medicine and emergency medicine), the definition of a CFTE depended on the specific specialty, whether faculty worked daytime or nighttime shifts, and whether faculty were based at the primary AMC or at satellite, geographically distant sites. One chair at an affiliate indicated that their emergency medicine faculty were stratified into “academic-heavy,” “academic-light,” and “community” tracks, following a discussion with and support from faculty (Table 2). Faculty in the academic-heavy track worked with trainees and thus saw more patients within a defined period than physicians in the academic-light and community tracks. They were expected to spend about 40 hours of a 60-hour work week on academic pursuits, including work on manuscripts, grants, innovations, and curriculum development and dissemination. Physicians chose the academic-light track if they were unsure about their own plans to pursue a fully academic career. In this track, they set their own pace and spent less time with trainees, more time in the community, and supported their own academic work.

Definition of academic time

“Academic time,” a phrase that was used in these interviews, was typically 1 day a week (range 0.5–3 days) for nonshift specialties and was variably defined for shift specialties. For hospitalists, this was loosely defined as time not involving clinical work or supported by a grant or other funding. An emergency medicine leader at one affiliate quantified nonclinical time as 400 hours per year, but this was not consistent across affiliates.

With the exception of radiology leaders, departmental and divisional heads generally reported that time meant for academic activities was typically used for administrative work and/or to catch up with clinical notes and was rarely considered “true” academic time. In fact, “academic time” was reframed as “nonclinical time” by one respondent. In radiology, one chair defined an “academic day” as a workday when professional staff members were free of clinical responsibilities and time was expected to be spent on research and other academic pursuits. This was available to those whose CFTE exceeded 0.6 and was in addition to discretionary time off or conference time; however, staff were still available by pager during academic time. A radiology leader at another affiliate indicated that all professional staff members received 0.5 days per week for nonclinical work funded by the department. Any staff member could get an additional 0.5 day of academic time weekly if they developed a promising research proposal, with expectations of results in 6–12 months. Staff members publishing at least 3 papers per year were awarded an additional 0.5 day of academic time weekly.

Resource availability and best practices for supporting academic advancement

Although most departments provided some portion of an FTE to faculty mentors in leadership positions and/or ensured 1–3 dedicated mentors for junior faculty members, there was variability across departments in other resources for academic advancement (Table 3). Respondents viewed themselves and other mentors as sponsors as well. Coaching was sometimes provided to departmental leaders but was typically not available to faculty, except for remediation purposes. Some departments had invested resources in intensive programs for mentorship and academic advancement, and in 2 departments, expectations of academic productivity were built into the program for accountability (Table 3).

Table 3:

Selected exemplar programs for supporting academic advancement

Department	Summary of program
Radiology	Assigned mentor for each faculty member; mentor–mentee dyads meet 4 times/y Mentors provide reports of the mentoring partnership and outcomes to departmental leadership 1 time/y
Surgery 1	Mentorship program for junior entry-level faculty with a midcareer boost; includes mentors from other departments, affiliates, and even outside HMS Wellness Committee offers free coaching, but mostly as a component of remediation Promotion adviser available for faculty 2 full-time employees available to write promotion letters, letters of recommendation, and help with grants
Surgery 2	Engage trainees in academic efforts early in their careers: Departmental faculty mentor trainees through a Clinical Scholarship Program and Surgical Program in Innovation, which allow for scholarship to advance for faculty as well; expectations of accountability are built into the program Strong clinical research infrastructure that includes coordinators and biostatisticians, with guidance provided around protocol development and research training: Facilitating Innovative Research and Surgical Trials Program
Ophthalmology	Harvard-wide Ophthalmology Mentoring program: each promotable faculty has 2 mentors assigned; mentors and mentees sign a contract to meet regularly Encourage faculty to attend the HMS leadership course and national leadership courses within ophthalmology societies Harvard-wide retreat, which often has a theme of wellness and how to promote this across the workforce Wellness Committee
Emergency medicine	2 faculty members each year participate in the affiliate’s leadership program 1 female faculty member each year participates in a separate leadership development program for women 6 faculty in entry-level leadership positions are mentored by senior departmental leaders in an Emerging Leaders Program, which offers coaching, mentoring, and readings Every individual has a senior mentor and is mentored by the division or section chief

HMS, Harvard Medical School.

There was substantial variability in resources available for continuing medical education within departments and across divisions, with reported annual professional funds ranging from $500 to $10,000 per person, with larger funds from the departments of radiology, surgery, and ophthalmology compared to other specialties.

Barriers to faculty support and advancement

Concerns were raised by chairs of internal medicine, pediatrics, and psychiatry and, to some extent, emergency medicine regarding documentation burden and its deleterious impact on academic time, wellness, and retention. Components of documentation reported to be particularly burdensome included having to complete clinical outpatient or inpatient notes during off-hours and keeping up with electronic health record workflow management systems. Some departments (eg, internal medicine, pediatrics, and psychiatry) in certain affiliates perceived that faculty disenfranchisement was manifested by faculty leaving academia for positions in industry.

In contrast, burnout in radiology was reported to be consequent to the physical strain of work (eg, development of carpal tunnel syndrome). This led to an increased focus on better ergonomics for physicians. Further, home workstations were deployed to enable faculty to work from home if necessary. Departments of surgery at 3 affiliates indicated that documentation burden was less of an issue with their faculty, who shared note templates and were parsimonious in their notes while documenting sufficient information to meet clinical and billing standards. Similarly, a chair in ophthalmology indicated that burnout was related not to documentation burden but, rather, to challenges in switching to a new electronic health record system following system integration, a burden that was regarded as temporary.

Although not specifically elicited, information regarding physician compensation was volunteered during many of the interviews in relation to the definition of a CFTE, academic time, and faculty barriers to academic advancement. Departments differed greatly in their compensation plans. Some respondents indicated that faculty believed that their compensation should be higher and that they should be compensated for certain teaching, administrative, and other roles that were currently uncompensated in their division or department (eg, ward-based and clinic-based teaching; roles serving as a member on task forces, working groups, and promotion committees; successful scholarship and grant funding).

Discussion

The authors aimed to understand differences and commonalities across departments and hospitals in the definition of a CFTE, the amount of time available to clinical faculty to engage in academic work, how clinicians are perceived to use nonclinical time, and efforts in departments to enable clinical faculty to succeed academically by interviewing a purposive sample of clinical department heads at HMS affiliate institutions. The findings of this study indicate substantial variability across clinical specialties in time allocation for clinical work (particularly for shift vs nonshift specialties, as well as within shift specialties) and in resources available to enable academic success. There is also substantial variability in the amount of spillover of clinically related work in documentation, billing, and test follow-up that is inherent to the specialty, which may result in undercounting of the time required for clinical work. National data suggest that faculty spend more than 45 minutes nonscheduled time daily on electronic record related tasks; primary care faculty spend the largest amount of time at > 115 minutes daily.²⁰

The lack of consistency in how departments determined, defined, and operationalized a CFTE was striking. This is to some extent expected in that various affiliates (rather than a single medical school employer) act as employers for their respective faculty and therefore set hospital-specific standards for job descriptions and compensation. Further, determinations of how many clinical sessions comprise 1 CFTE in subspecialties appeared to be relatively heterogeneous and dependent on both workload and finances. This could be explained in part by differential insurance reimbursement per wRVU across specialties, but the authors also saw different approaches across affiliate hospitals for presumably similar clinical work.

Other medical schools with affiliated but independently operated hospitals might find similar variation in determining a CFTE, and given the risks of faculty disenfranchisement,⁶ could consider establishing best practices in the definition of a CFTE across departments to optimize physician vitality and reduce burnout.⁶ These standards may need to accommodate specialty-specific factors (eg, shift-based, procedural, amount of documentation). This complex task may also benefit from a nationwide standard to ensure that reimbursement models reflect time spent both during and after the visit on documentation and follow-up. Appropriate wRVU credit and reimbursement would allow physicians to reduce the number of patients seen per clinic session or the number of sessions that count toward 1 CFTE for the same compensation and reduce documentation burden. A key benefit would be increased time available to teach trainees during clinic time, something that has been associated with improved trainee evaluations and which may be recognized in promotion and, therefore, enhance career advancement. Strengthening the training environment would overall benefit the institution. Data indicate that high clinical service intensity in terms of annual wRVUs and patient encounters, at least in certain clinical specialties, contributes to negative trainee evaluations.² Lower physician stress overall should contribute to improved practice performance and care provided to patients.³

The authors also found that paid time when not doing direct patient care was mostly used for administrative work and/or to catch up with clinical work, not as “true” academic time by most clinical specialties, as supported by the literature.²¹ One respondent, in fact, reframed “academic time” as “nonclinical time,” a more accurate representation of how clinical faculty are using this time. Yet, a few departments have successfully defined and set aside dedicated time for academic work, building in accountability mechanisms. The authors endorse the value of sufficient academic time as essential for clinical faculty to meet milestones for promotion (which contributes to wellness),^6,14,15,22 especially when that time is used toward endeavors supporting academic productivity. A related consideration that was not addressed in the authors’ interviews was the concept of “career fit,” with data indicating increased burnout when physicians are not spending at least 20% of the time in their desired role.¹¹ This will need to be explored further in future studies. Finally, although most departments have some form of mentoring and sponsorship, others have been more purposeful in developing structured programs with clear expectations.²³ Such programs (eg, Surgery 2 in Table 2) also benefit trainees, who are in turn mentored by junior and midlevel faculty.²⁴ Importantly, mentoring, sponsorship, and coaching can optimize faculty recruitment and retention.^22,25

Limitations of this study include, first, that this was not a formal qualitative study and, as such, did not include rigorous procedures, such as multiple coders, codebook development, trustworthiness, or participant checking. Instead, it was intended to generate exploratory high-level findings to inform future directions for inquiry. Content analysis was based on primary data keyed to probe questions informed by the study aims and based on detailed interview notes rather than transcripts from recordings. The findings of the present study lack divisional-level detail, particularly for large departments, such as internal medicine, pediatrics, and surgery. The authors interviewed chiefs of hospital medicine and primary care within the department of medicine, but other divisions were not represented. Second, not all departments were included, and it will be important to assess specialties, such as obstetrics and gynecology, orthopedics, radiation oncology, anesthesiology, and pathology, for specific issues raised through this work. Third, the authors spoke to department chairs and division chiefs; future work should represent perspectives of clinical faculty for a thorough understanding of time devoted to clinical work, and in particular, the spillover into unscheduled hours, as well as barriers to academic advancement. Moreover, the authors did not uniformly receive information regarding compensation related to CFTE definitions. Finally, the authors did not query chairs on the important issues of diversity, equity, and inclusion and how these factored into responses to the authors’ questions,^26,27 and a minority of the leaders interviewed were women and none were underrepresented in medicine (reflecting the general underrepresentation of certain groups in positions of leadership). These gaps will need to be assessed in future research. In addition, there are clearly some faculty who are academically productive despite insufficient protected time, and although self-motivation is likely a contributing factor, additional research is necessary to understand determinants of academic productivity in these individuals so as to promote equitable access to opportunities for career advancement.

Conclusions

Physicians choose to work in academic medicine for reasons that include training the next generation, performing research that directly impacts patient care and addresses the needs of the community, and providing high-quality clinical care. Optimizing the definition of a CFTE and academic time and providing resources to enable academic work could increase prospects for promotion, improve job satisfaction, and therefore, faculty retention. Future inquiry should focus on the extent to which the observed differences in CFTE definition based on specialty, documentation volume, and shift-based work are common to other institutions. The authors also hope their findings will spur innovations in how academic time is safeguarded against competing clinical commitments. Hospital leadership and department chairs should consider these aspects when developing strategic plans and budgets that support the academic mission and administrative strategies to reduce documentation burden. Protecting academic time can enhance scholarly productivity, physician wellness, and retention in ways that may raise the quality of care in AMCs while enriching the value of their medical school affiliations.²⁸