Promotion

Abstract

This article gives an overview of the promotion process in an academic medical center. A description of different promotional tracks, tenure and endowed chairs, and the process of submitting an application is provided. Finally, some practical advice about developing skills and attributes that can help with academic growth and promotion is dispensed.

Objectives: Upon completion of this article, the reader will have an understanding of academic promotion systems.

One of the most important tasks for the chair of any department is to recruit, retain, and promote excellent faculty members. This process is intimately tied to the success of the faculty members in developing their careers, expanding their sphere of influence, and getting promoted up the academic ranks. It is not only beneficial for the individual faculty members but also creates a “culture of excellence” that projects a strong departmental image within the institution and across the country. This, in turn, attracts the best and the brightest to the department—success breeds more success.

For the faculty members, it is critically important to understand how the promotion and tenure system works and what they must do to succeed in an academic environment. In my personal experience, most of the residents have no more than a vague idea about the process, and are largely unaware of the precise milestones that they must meet to get promoted in an academic setting. They often do not understand the differences between the various academic tracks, their specific requirements, and what they have to do to move up the promotion ladder. Although the process of promotion and tenure is unique to each institution, this article is written as an overview for the residents, fellows, and junior faculty members. My personal experience as a faculty member at four different universities: Georgetown University School of Medicine, Uniformed Services University of the Health Sciences, Harvard Medical School/Harvard University, and University of Michigan Medical School (full professors at the last two) has taught me that despite significant interinstitutional differences in the actual process, the ingredients of academic success are nearly identical. This article describes the various types of academic tracks, differences between tenured and nontenured positions, and the process for promotion. At the end, I have added some personal advice and practical tips for success.

Academic Career Tracks

Academic medical centers today have multiple missions. This is reflected in the diverse skills sets of their faculty, and the very different criteria used in their evaluation and promotion. The classic model of medical academia was considered to be a three-legged stool with clinical care, teaching and research providing equal support, and an ideal recruit was the “triple-threat” faculty who excelled in all of these areas. However, in recent years complexity of all these tasks has increased exponentially and the chances of finding such a multiskilled person are becoming remote. In response, surgical departments are evolving in a fashion not too dissimilar from human societies, where different individuals play specialized roles based on their interests, skills, and training to create an optimal environment for all. In surgical departments, patient care remains the ultimate moral responsibility, but there are now four important pillars that support the complex enterprise: (1) professional work (including but not limited to clinical activity), (2) teaching, (3) scholarship (extending beyond the conventional definitions of peer-reviewed research), and (4) service (at the institutional, regional, and international levels). Most of the promotion committees now recognize that academic success can (and should) take forms that are very different from our conventional perceptions. In fact, universities are responding to the changing times by creating new definitions of academic activities. For example, Harvard Medical School recently revised their promotion criteria¹ to make them more flexible, and provide a “menu” of activities that would allow the candidate to assemble a profile that more reliably reflects the broad range of activities in areas of academic mission, clinical care, administrative leadership, and service to the community. This structure allows the sum total of an individual's achievements to be considered when being evaluated for promotion. The faculty members are expected to select one area that they consider to be their “area of excellence.” These include (1) teaching and educational leadership, (2) clinical expertise and innovation, and (3) investigation. In addition, they can report significant supporting activities in other areas. Similarly, the University of Michigan² offers promotion in the traditional tenure track (called the instructional track), but the faculty can opt for research and clinical tracks (nontenure) if they consider research or clinical work to be their main mission. Regardless of the selected track, all must still demonstrate a strong commitment to teaching, scholarship, and service to get promoted. At the Georgetown University,³ three tracks exist for full time faculty members, including the traditional tenure, research (nontenure), and clinical educator (nontenure) tracks. Almost all the universities now offer similar options and a junior faculty must decide early on in their career which one of the available paths is the most suitable for them.

Surgeons in most academic departments fall into one of the following broad categories based on their workload and academic interests.

1. Clinical Surgeon: These surgeons typically devote 80 to 90% of their time to clinical activities. The fact that they are in an academic setting (instead of private practice) mandates that they be committed to student and resident teaching (typically in clinical settings). As the revenue generating workhorse of the department, they often subsidize the academic missions of other members that generate less revenue (scientists, educators, etc.). But to get promoted, a surgeon cannot simply be engaged in clinical work, but must also establish himself as a leader in the field. In the absence of a strong scholarship, these individuals fail to establish themselves as regional, national, and international leaders and struggle to get promoted. It should be clear that longevity in a rank or position is not evidence of accomplishment, and it does not by itself justify promotion to a senior level. Similarly, running a busy clinical practice as a master surgeon does not lead to promotion unless these activities get translated into scholarly activities. Promotion to the senior levels of the clinical track requires scholarship as evidenced by peer-reviewed publications and other academic productivity.

2. Clinical Scholar: The focus for these individuals is not simply on clinical work but on balancing it with clinically relevant academic endeavors. These individuals still devote 60 to 80% of their time to clinical activities, but allocate substantial time to scholarly pursuits such as clinical trials, outcomes research, health services research, and innovations that advance the clinical field in the diagnosis, prevention, or treatment of a disease. These activities should create a record of scholarship, which may include reports of clinical trials, chapters, reviews, guidelines/protocols for treatment, and other clinical research publications. Historically, tenure track was the exclusive domain of surgeons engaged in basic or translational research, but nowadays prolific clinical scholars easily fulfill the criteria for advancement in the tenure track at most of the institutions.

3. Surgical Educator: Pursuing this track is different from having an interest and commitment to education, which is mandatory in all of the promotional tracks. To be successful, candidates must view education as their primary academic focus, and be committed to establishing themselves as a leader in the field of education. Most faculty members that select this path devote approximately 50% of their time to educational and/or administrative activities (e.g., residency program director, medical student clerkship director). In addition to being a superb teacher, they must establish a position of national and international leadership through their scholarly activities that may include publications of original research, reviews and chapters, development of innovative educational methods, curricula, assessment tools, training modules and courses, policy statements, etc.

4. Surgeon Scientist: This has been the traditional path for securing tenure (my choice), which in recent years has become less attractive due to the increasing complexity and cost of basic/translational research, decreasing extramural funding (especially federal funding), and need for substantial time allocation. The main goal for the faculty on this track is to develop a specific area of scientific investigation, and perform enough original work in this area to establish a program that is supported by extramural funding. This is time and resource intensive task that also requires some formal research training (research during medical school or residency, or a PhD). Junior faculty members on this track require substantial startup funds, mentorship and collaborators, laboratory space/equipment, and substantial protected time (40–80%) to be successful. The critical benchmark for success is obtaining independent external funding, which is impossible without substantial academic output in terms of high-quality peer-reviewed publications, and skills in grantsmanship. Despite all these challenges, this option remains attractive to many as a way to rise rapidly through the academic ranks and gain national and international recognitions in their field.

What Does It Actually Take to Move Up the Academic Ranks

Promotion from an instructor to the level of a full professor requires proof of increasing influence and reputation, as established by scholarship, funding, and testimonials from leaders in the field. Broadly speaking, the requirements for promotion to different academic ranks are as follows:

1. Instructor: Training relevant to chosen career path and willingness to fulfill responsibilities of academic position. Some institutions have eliminated this position making assistant professorship the entry level position.

2. Assistant Professor:

   1. Local or regional stature

   2. Progress toward becoming a scholarly leader in their field

   3. Participation in relevant professional organizations

   4. Contributions to institutional missions.

3. Associate Professor:

   1. National or regional stature

   2. Recognition by peers for significant scholarly contributions to their field

   3. Emerging role as a thought leader in relevant professional organizations

   4. Substantive participation in institutional missions and citizenship.

4. Professor:

   1. National and international stature

   2. Significant impact on their field

   3. Recognition as a thought leader in relevant professional organizations

   4. Ongoing commitment to institutional missions and citizenship.

As individuals move up the ladder, they are expected to develop a coherent body of scholarly work that establishes their reputation as a leader in their chosen field. The exact number of publications needed at each level of promotion is rather difficult to determine as it varies from institution to institution. The promotion committees review many variables in addition to the number of articles, and the quality of the article (e.g., impact factor of the journal) also plays a significant role. However, at the University of Michigan Medical School, recent promotions were associated with the publication record⁴ given in Table 1.

Table 1. Publication record.

Rank	Time in rank (years)			Publications
(From to)	Average	Median	Mode	Average	Median	Mode
Assistant to Associate Professor	6.3	6	7	34	30	20
Assistant to Associate Professor (research)	7	6	4	42	38	44
Associate to Full Professor	7.2	6	6	63	57	40
Associate to Full Professor (Research)	7.3	7	7	58	58	70

Thus, a successful associate professor publishes 8 to 10 good quality articles per year (or 1 every 6 weeks) because the time to reach your goal is limited. At Michigan, tenure must be achieved by the end of 10th year by individuals that are in tenure track positions. There is really no time to waste if securing tenure in one of your goals.

What Is Tenure?

There are several misconceptions about what tenure means and what it provides. It is not a legal contract, nor a salary guarantee, and certainly not an absolute security against losing the job or academic title. It, however, is an endorsement of your academic accomplishments and recognition of your value to the institutional missions and values. Tenure was first developed in the middle ages to provide academics protection against religious fanaticism and authority. The goal today is to shield the faculty against external pressures and coercion. In theory, it provides job and salary protection so that the faculty member can pursue professorial activities without worrying about the consequences of challenging existing dogma. This freedom promotes critical thinking by a group of intelligent, competitive, and highly selective individuals who are at the top of the academic pyramid, which pushes the boundaries of knowledge and results in major advancements. As tenure is given to a very few individuals, it is widely acknowledged as a badge of academic excellence. However, tenure does not mean that a faculty member can stop being academically or clinically productive, shrink his teaching responsibilities, or be delinquent in his citizenship duties. This is especially true for surgeons, whose salaries are much higher than tenured professors in nonclinical fields. In most institutions, the salary that is guaranteed by the tenure is a portion of the university “base” salary, without taking into account the clinical differential. The exact rules differ by institution, but loss of clinical productivity can result in a dramatic loss of income for the surgeon, regardless of tenure. You should pursue tenure as a badge of academic excellence and not as an insurance policy.

Endowed Professorship

Appointment to an endowed professorship (or endowed chair) is the highest honor that the university can bestow on a faculty. This is a position permanently paid for with revenues from an endowment fund specifically set up for that purpose. Typically, the position is designated to be in a certain department, and the donor is allowed to name the position, which typically takes a “First-name Last-name Professor of Department-name” format. Endowed professorships aid the university by providing salary support for their best faculty members. It also tremendously helps the recipients by freeing them from the demands of generating clinical revenues to focus more on the academic mission. In addition, endowments provide funds to support the various academic endeavors that are high priority for the recipients. In the era of decreasing extramural research funding, these endowments allow the universities to attract the top talent and support various academic missions.

Process of Promotion

The specifics of the process are unique to each institution, and all new faculty members must take time to educate themselves about all of the details. A brief, general summary is provided there to highlight some key components and steps of academic promotion.

In most surgical departments, annual performance evaluations include a determination of whether the faculty members are meeting the milestones for timely promotion in their selected academic tracks. Once an individual is deemed to be ready for promotion by the division chief and the departmental chairman, he is asked to assemble a “promotion package” for preliminary evaluation by a departmental/internal promotion committee. Once approved internally, it is formally submitted to the full promotion committee at the medical school for approval. This is typically followed by additional scrutiny such as approvals by an executive committee and the dean. At the University of Michigan, assistant professors and other untenured members of the teaching staff are appointed by the president of the University upon recommendation by the dean and the executive committee. However, only the Board of Reagents of the University has the authority to make the tenured appointments. Regardless of the specifics, at all the universities, it is a long and tedious process that becomes increasingly more rigorous as you move up the ranks.

To optimize their chances of success, the candidate must invest time and effort into meticulous preparation. The submission of application requires a deliberate approach.

1. Read the latest version of promotion criteria carefully and completely. Most schools provide it online.

2. Determine if you are ready. If not, make a note of the deficiencies, develop a practical plan to fill the gaps and do not rush into submitting your application prematurely. Most of the departments have formal systems in place that not only determine the eligibility of the candidate for promotion but can also provide valuable feedback about deficiencies that may not be obvious to the junior faculty member. These typically include:

   1. Division chief

   2. Chairman

   3. Departmental promotion/review committee.

3. Prepare the promotion package and submitted it well ahead of the due date. A typical promotion folder includes many components, such as:

   1. Cover letter

   2. Curriculum vitae (in specific format) with full bibliography

   3. Educator/teaching portfolio

   4. Research portfolio

   5. Description of clinical responsibilities

   6. Grant funding

   7. Copies of selected peer-reviewed publications with descriptions of impact and relevance to a specific field

   8. Letters of support (from individuals who hold academic rank equal or higher than the requested promotion)

      1. Chairman

      2. Internal (within the institution)

      3. External (experts in the field).

Typically, the hardest letters to obtain are from external experts that are at “arms-length” from the candidate. This often makes previous colleagues, mentors, collaborators, coauthors, etc., ineligible to write letters in your support. In essence, the idea is that if you are applying for professorship, experts in the field should know you based on your national/internal reputation and your body of work. You must select the reviewers carefully in consultation with your chairman. Typically, it is desirable to invite well known reviewers (from prestigious institutions), but these individuals also tend to be the busiest and the most likely to be tardy. Typically, the final list of selected reviewers is a mix between some that are suggested by the candidate and the ones that are proposed by the chair.

The bottom line is that promotion recognizes excellence at national and international levels. Remember that timeline is long, the process is tedious, and it requires meticulous attention at every step.

Tips for Success

The following practical tips are based on my experiences and observations over many years in academia, and thus reflect my personal biases. I acknowledge that this list is far from exhaustive and many experts may disagree with my opinions.

1. Published word is the currency of academic promotion. My most important advice for the aspiring professors is to write everyday. If writing regularly is not for you then the sooner you give up the academic dream, the better.

2. You need to generate first authored publications early in your career (and senior author articles after reaching mid-level). Being in the middle of a long list of authors does not impress anyone.

3. Promotion committees tend to count much better than they can read, so the total number of publications is really important. It is great to have Nature and Science articles, but it is equally (and probably more) important early in your career to just publish a lot.

4. Make sure that you have selected the right academic track before you sign your first job contract. The resources at your disposal, protected time, and expectations for clinical productivity are tied to this critical decision.

5. Start assembling the promotion package on your first day at the job. It will take approximately 5 years to fill in the gaps and make it perfect.

6. Effectiveness in time management (not intelligence, ambition, or hard work) most often separates those who succeed from those who fail.

7. Find a good mentor early in your career. When you change jobs, do not lose touch with the old mentors. Depending on your academic track, you may need multiple mentors.

8. Develop a theme in your academic work early. You are creating an “opus magnum,” it should be a coherent body of work. Keep it broad enough to allow for growth over the next 10 to 15 years.

9. Watch out for yourself. Self-promotion is not a sin but you must do it intelligently and honestly.

10. Build a place for yourself on the national stage. You will need letters of support from leaders in your field, and you just cannot earn their esteem overnight. This is at least a 10-year project, so start it now. Join professional societies, accept invitations to give talks and grand rounds, join discussion groups, policy writing groups, and committees that formulate consensus statement.

11. Independent funding is critically important. Master the skills of grantsmanship, and apply for funding relentlessly. Get a mentored grant early (K award) and submit applications for independent funding yearly, starting year 3.

12. Teach well and pay close attention to your teaching evaluations. Regardless of the specific academic track, a mediocre teaching portfolio will hurt your chances and really bad evaluations can sink the ship.

13. Your success will attract trainees, collaborators, and mentees that will make you even more productive and expand your sphere of influence. Remember that their success is your success. Share credit generously, and promote their careers aggressively. It is a long-term investment so do not try to cash in early.

14. You (like everyone else) can improve. Academic success is a learned trait. Seek candid advice from mentors and your peers early in your career. Attend career development courses given by academic professional societies, university, and/or your own department. Constantly think about what you can change to get better.

15. Develop productive teams and establish networks. Research (clinical or basic) is no longer a one-man show (maybe it never was). Your success over the course of your academic career will depend on the people around you.

16. Marry the right person! Striving for academic excellence is a life-long quest. Your spouse and children, as well as other family members must share your vision and be willing to support you through the long and often very demanding process. You do not want to win this race and be alone at the finish line.

A Word about Time Management

To balance a clinical practice with a successful academic career is tough, especially when you also throw in work-life balance, personal fulfillment, and competing family priorities. Countless books have been written about time management, and about ways to enhance your effectiveness. Some of these are actually very good,^{5 6} and I often give copies of these to my research fellows and residents. However, none is a replacement for learning directly from the individuals who do it well. There are individuals (and I am sure that you know some in your own environment) who have figured out how to achieve the perfect balance, set up the correct priorities, maintain a healthy (not all consuming) clinical practice, find time to teach, obtain grants, write articles, and to not miss the important family events. This is never easy, and there is no magic formula. You must make sure not only that there is no time wastage but that your time is allocated appropriately to high priority areas. Defining what “high priority” is uniquely personal, and it often evolves as one goes through different phases of life and academic career. However, this is an area that needs your utmost attention. Do not leave it to others to decide where your time should be spent. In my opinion, success or failure in this arena is one of the most fundamental determinants of long-term academic productivity. On a personal front, optimal time utilization has been an ongoing quest. I am ferociously protective of my time as this is really the only resource in my life that I just cannot generate. Simply stated—you can always make more money but wasted time is gone forever. One must know exactly where their time goes. There are 168 hours in each week—you should be able to account for all of it and be in control of its allocation. It is often tough for a junior person to set their priorities appropriately. They may not even have much real control over big chunks of their working hours. But they must aggressively control whatever time they can control and then slowly add to this block. Most of the activities at work place are not inherently wasteful, but how to strike the right balance is often confusing. For example, administrative duties and institutional citizenship are important activities, but which committee assignments are better than others, and exactly how many hours per week should be allocated for these activities? Unless carefully managed (and frequently recalibrated), these activities can become a bottomless time trap. This is one area where advice from a seasoned mentor is invaluable. Set clear priorities, delegate what you can, learn to say no, and revisit your priorities frequently. During these deliberations, set aside time for issues that are important for your happiness, health, family, and personal growth. Remember that you will be in this field for 30 years, and nobody can be successful over such a long time, with self-deprivation as their main strategy. Mid-career burnout is a real problem for surgeons.⁷ Make time for hobbies, family, exercise, travel, vacations, and other things that make life worth living. Your goal is not to achieve academic success at any cost, but to do so while leading a meaningful, productive, and fulfilling life.

Final Thoughts about Scheduled Writing

There is no getting around this reality. One of the biggest differences between academic stars and the wannabes is their ability to write clearly, on schedule, and to do so over a long career. Writing (a lot) is essential for academic success, but it is not inherently a fun activity. Most surgeons are not good writers,⁸ but with practice and coaching we can all improve.⁹ Similar to time management, there are numerous good books^{10 11} that provide practical advice about how to become a more prolific academic writer. Regular writing is a lot like regular exercising. Even though you know it is good for you, it is really difficult to stick with it. However, the more you do it the easier it gets and before long it becomes a part of your life.

Academic writing is not limited to peer-reviewed publications. Whether it is the grant proposal that will fund your future research, guidelines that streamline clinical care in your hospital, or web-based teaching tools for your students, writing is at the core of nearly all academic activities. Thus, it is striking how few junior surgeons actually have “writing time” on their daily schedules. Their daily calendars are full of activities with questionable academic worth, but writing is routinely put aside for the “free-time” that never materializes. Some of the common excuses that I hear from the junior faculty members to justify their lack of writing include:

1. I just never seem to have enough free time. This is by far the commonest excuse. Just remember that everyone has the same 24 hours each day. If you do not have enough writing time, then you need better time management skills. Make it a priority and get “writing time” on your schedule.

2. Too busy with clinical work, but will write more when I get more protected time. Waiting for change is futile. Actions lead to a change. You have four options: (1) use the existing discretionary time more efficiently, (2) reset priorities to free up time, (3) look for another job, or (4) kiss your academic promotion goodbye.

3. I do not feel inspired right now. Remember that this is not creative writing, and you are not Shakespeare. You are not expected to move people to tears with your inspired writing. Just sit down and write the article that you have been avoiding for weeks.

4. I have nothing to write about (or no desire). Now, this may be a real issue. My suggestion would be to start looking for a nonacademic clinical job soon.

In summary, to be a prolific writer, writing time must be on your schedule, and it must be used effectively. Here are some practical tips:

1. You must write everyday if possible early in your career, or at least three times per week.

2. Ideally, block a 2-hour slot for writing when you are at your most productive (early morning for me). Use the first 15 minutes to plan and get your thoughts together, and then write for 45 minutes. Take a few minutes break, and then write again for 45 minutes. Use the last 5 to 10 minutes to plan for the next session. No e-mails, phone calls, or web-browsing unless directly related to the writing task in hand. The formula is fairly simple—larger blocks of effective writing time = more scholarly output = faster academic growth and promotion.

3. Early in this process, sticking with the schedule it is more important than the actual quality of the work. Quality will eventually improve.

4. If you cannot stick with the schedule then figure out why.

5. Avoid binge writing close to deadlines. Hopefully, once you become a scheduled writer you will not have to worry about this point.

6. With some practice, compliance with the schedule will no longer be a problem. Now, it is time to set specific goals for each writing session. This could be pages/hour or chapters/week or some other measurable matrix. Then see if you can slowly increase your output. Set up “due dates” for tasks (even if not mandated by external agencies) to have internal goals, for example, first draft of the article by March 1. Now is the time to focus more on the quality of your writing.

7. Create your “writing cave.” Whether it is a favorite chair or a comfortable pullover, or an old pen—if there are tools and props that enhance your effectiveness then please use them. Avoid distractions, close the door, and hand the pager to your assistant.

8. Set priorities for each writing sessions. Tackle the top item before moving down the list. This ensures that even if you get interrupted (which will inevitably happen), all will not be lost.

9. Reward yourself for meeting deadlines and targets. Whether it is a nice cigar on the patio, or a fancy dinner—you deserve it.

10. During peak writing times (e.g., grant submission time) make a conscious effort to not lose the balance. Do not cut back on sleep, eat healthy, do not skip exercise, and make time for the family. You are unlikely to deliver your best performance when sleep deprived and exhausted.

11. Writing has an amazingly long learning curve. Even seasoned writers report that they continue to improve after many decades. You will develop your own style, but in my opinion, scientific prose should be focused, brief, and direct. Presentation of data is a logical process, so avoid long convoluted sentences. “Learn to cut,” and use short and simple sentences. Remember, you are not Tolstoy writing War and Peace.

12. When an article comes back for corrections, revise and resubmit within a week unless there is a compelling reason for delay (e.g., need for additional experiments).

13. Do not give up if the article is rejected for publication. It is time to go back to the drawing board. Re-evaluate the data in light of critique from the reviewers, rewrite the article, and resubmit to a different journal.

14. The key to academic success is to write, write, and write.

I have had the extraordinary privilege to pursue my academic dreams at some of the finest institutions of higher learning, and to interact with amazingly gifted individuals. There is no universal formula for success. However, as I see it, the basic requirements for academic success can be distilled into just a few lines:

• Excellent time management skills

• Polished writing skills and an ability to write on schedule

• Meaningful research interest

• Good mentors

• Balanced lifestyle.