Robert F. Jones

Faculty appointment and tenure policies in medical schools: a 1997 status report.

The authors present recent data on changes under way in and the current status of faculty appointment and tenure policies in U.S. medical schools. The data are drawn from a survey conducted by the Association of American Medical Colleges in 1997, to which deans at all 125 U.S. allopathic medical schools responded, supplemented by follow-up telephone and electronic mail inquiries. Faculty evaluation systems and faculty compensation systems top the list of areas in which medical schools are most frequently making policy changes, with approximately half of the schools involved in each area. Changes in evaluation systems reflect an increasing emphasis on post-tenure review. Changes in compensation systems are characterized by the division of pay into separate components, each with its own financial guarantees and with the level of compensation tied specifically to measures of individual and group productivity. Other policy changes include introducing new faculty tracks and career pathways, redefining or clarifying the portion of salary or compensation that is defined by tenure, lengthening the pre-tenure probationary period, and modifying the link between promotion and tenure. Of the 125 medical schools in the United States, only five do not award tenure, while another six effectively limit eligibility for tenure to basic science faculty. These numbers are unchanged from those reported in 1994. Only two schools indicated that eliminating tenure or ceasing to make tenure-eligible appointments was being considered, and neither reported that a policy change was imminent. Current data on the status of tenure guarantees, tenure probationary periods, other tenure eligibility criteria, and special clinical tracks are provided. Nearly three fourths of the medical schools in the United States now have a separate and distinct faculty track for full-time clinical faculty whose primary responsibilities are in patient care and teaching. The vast majority of these tracks do not permit faculty to be tenured, but 71% require evidence of scholarship for promotion. The authors conclude that faculty personnel policies in medical schools are likely to continue to evolve, consistent with a growing insinuation of the corporate culture into academia.

On the Cost of Educating a Medical Student.

The cost of educating a medical student has been an issue of intermittent public concern for most of the twentieth century, beginning in 1910 with the Flexner Report. The issue is now reemerging as a topic of high public and political interest, for several reasons, including concern about medical schools and their financing. Estimates of medical student education costs appear to vary widely; but such variations derive from the different ways the question has been framed. Costs can be categorized as instructional costs and total educational resource costs. Instructional costs, which can be distinguished further as marginal costs or proportionate-share costs, are those costs that can be related directly to the teaching program and its support. Total educational resource costs are those costs supporting all faculty deemed necessary to conduct undergraduate medical education in all their activities of teaching, research, scholarship, and patient care. The authors review studies spanning a period of more than 20 years and find that instructional cost estimates of medical student education, when adjusted to a standard base year (1996 dollars), fall within a fairly narrow range: most are between

The Present and Future of Appointment, Tenure, and Compensation Policies for Medical School Clinical Faculty

40,000 and

How Do Medical Schools Use Measurement Systems To Track Faculty Activity and Productivity in Teaching

50,000 per student per year. Estimates of total educational resource costs show greater variation, but four of six estimates fall between approximately

Organizational models for medical school-clinical enterprise relationships.

72,000 and

Validity of the MCAT in predicting performance in the first two years of medical school.

93,000 per student per year. The authors note that present directions of curricular innovation-small-group learning, investment in information technology, and clinical education in ambulatory sites-offer little solace to those concerned with mitigating the costs of medical student education. Several proposals have been advanced to restructure medical student education in the name of efficiency and cost-effectiveness, but many are simply maneuvers to transfer responsibility for costs to other entities. Only by a net reduction of the medical school curriculum might costs truly be reduced. Yet the medical knowledge base continues to increase, as does the range of information and skills required of medical students. Unless society is prepared to change dramatically its concept of the well-educated physician, opportunities for significant reductions in the costs of medical student education are difficult to visualize.

Tenure policies in U.s. and Canadian Medical Schools

The authors present data and information about appointment, tenure, and compensation policies to describe how medical schools are redefining the terms under which they relate to their full-time clinical faculties. First, the authors note the increasing differentiation of clinical faculty members into two groups, researchers and clinicians. The present-day competitive realities of both research and clinical enterprises have prompted this change and the principles of mission-based management are reinforcing it. Second, they document the long-term tendency of schools to appoint new clinical faculty members to contract-term (as opposed to tenure) appointments, as special non-tenure-eligible tracks for clinically oriented faculty proliferate. Third, they report on the policies of schools to limit the financial guarantees provided to clinical faculty members who are awarded tenure. For schools that have yet to address this issue, they discuss the various employment and pay arrangements that inform or confuse the question. Fourth, they describe historic problems with clinical faculty compensation arrangements and illustrate, with examples from ten schools, the characteristics of recently implemented performance- and risk-based compensation plans. While these trends in institutional policies and practices may initially concern faculty advocate groups, the authors argue that they may serve the long-term interests of those groups. The terms of relationships between medical schools and their clinical faculties are tied closely to the specifics of organizational structure, which are currently undergoing review and change. The challenge all schools face is to define these terms in ways that allow them to continue to attract high-quality clinical faculty while avoiding an insupportable financial liability.

The Effect of Commercial Coaching Courses on Performance on the MCAT.

The authors describe their findings from a study that (1) identified 41 medical schools or medical school departments that used metric systems to quantify faculty activity and productivity in teaching and (2) analyzed the purposes and progress of those systems. Among the reasons articulated for developing these systems, the most common was to identify a “rational” method for distributing funds to departments. More generally, institutions wanted to emphasize the importance of the school’s educational mission. The schools varied in the types of information they tracked, ranging from a selective focus on medical school education to a comprehensive assessment of teaching activity and educational administration, committee work, and advising. Schools were almost evenly split between those that used a relative-value-unit method of tracking activity and those that used a contact-hour method. This study also identified six challenges that the institutions encountered with these metric systems: (1) the lack of a culture of data in management; (2) skepticism of faculty and chairs; (3) the misguided search for one perfect metric; (4) the expectation that a metric system will erase ambiguity regarding faculty teaching contributions; (5) the lack of, and difficulty with developing, measures of quality; and (6) the tendency to become overly complex. Because of the concern about the teaching mission at medical schools, the number of institutions developing educational metric systems will likely increase in the coming years. By documenting and accounting financially for teaching, medical schools can ensure that the educational mission is valued and appropriately supported.

The End of Mandatory Retirement and Its Implications for Academic Medicine.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers—models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.

Preclinical Curriculum Characteristics and Institutional Performance on NBME Part I.

In this paper, the authors present the first systematic summary of predictive validity research on the new Medical College Admission Test (MCAT) since its introduction in 1977. Data are drawn primarily from the MCAT Interpretive Studies Program, a cooperative effort between the Association of American Medical Colleges and 30 of its member schools to conduct research that will both facilitate local use of the test scores and contribute to a national perspective on their value in medical school admissions. The results show that MCAT scores by themselves have significant predictive validity with respect to first- and second-year medical school course grades and National Board of Medical Examiners Part I examination scores and that they complement the predictive validity of undergraduate college grades. The MCAT Science Knowledge areas of assessment, particularly Biology and Chemistry, and the Science Problems subtest tend to have higher correlations than the Skills Analysis subtests with initial performance in medical school; however, the Skills Analysis: Reading subtest may retain its predictive value best over time. Correlation values are discussed in terms of methodological factors which constrain their size. They are also compared with those found for other professional and graduate school admission tests. Further directions for MCAT validity research are described.