Parsing promotions for academic hospitalists
The scarcity of full professors in hospital medicine relates to the challenges of publishing while working as a hospitalist, a researcher explains.
ACP Member Christiana S. Renner, MD, worked as a high school teacher and a production editor before she became a physician. But when she entered academic hospital medicine, she found that career progression worked a little differently than in those other fields.
“I was struck by how little faculty development there was,” said Dr. Renner. “It became a passion of mine, basically trying to figure out how to help people to move forward, especially given the changing landscape of promotion, which is very variable by institution and also by department.”
Dr. Renner and her colleagues looked at this variability by evaluating 122 hospital medicine full professors who practiced at academic medical centers ranked in research by U.S. News & World Report. The study analyzed the physicians' scholarly productivity by quintile based on publications, academic medical center research ranking, years postresidency, and grant funding.
“It's a big, big task to take on all of general internal medicine and its subspecialties, so we just decided to focus on hospital medicine—it's a much smaller field and finished its first 20 years recently,” said Dr. Renner, who is an associate professor of medicine in the division of hospital medicine at the University of Texas Southwestern Medical Center in Dallas.
Overall, the professors had a median of 15.0 publications, with medians of 175.5 and 0.0 publications in the top and bottom quintiles, respectively, according to the study, which was published by the Journal of Hospital Medicine on June 27. Full professors on faculty at the top 20 academic medical centers had a median of 35.5 publications versus a median of 3.0 for professors at centers ranked No. 81 to 122. Scholarly productivity was higher among grant-funded versus non-grant-funded professors, and female professors had a mean of 26.4 publications compared to 59.5 for men.
Dr. Renner recently spoke to ACP Hospitalist about the study's findings.
Q: What about your results surprised you?
A: There's a 2012 study we referenced that looked at the number of associate and full professors in hospital medicine, and I was honestly surprised that the needle has not moved since then. I expected that as we evolved as a specialty, there would be more attention paid to mentorship and growth, and so I was surprised that the overall percentage of full professors was about the same. The caveat is that some of that might be due to the growth of the field, so you might have more full professors, but there's just so many more hospitalists and academic medical centers that that percentage has stayed the same. But I do think it's concerning for the field in general, because the mentorship for growth within a department usually comes from above.
Q: What effects might the shortage of full professors have on hospitalists?
A: We put a lot of workload on hospitalists, and if we're not supporting career growth and development, then are these people then leaving hospital medicine to go do something else because they feel like there's no opportunities, and they just see this 20-year career lying in front of them, doing the same thing for 20-plus years? Is it causing more turnover, or is it more costly to the profession as a whole? How do we retain that talent and grow the field?
The mentorship piece is crucial. When I talk to my younger, newer colleagues, I try to sit down with them and find out what their interests are, what their goals are; then I try to help them find a mentor who's aligned with their interests. Mentorship doesn't necessarily have to be in your own department; it can be with someone in a different department, as long as you work well with them, and they are willing to talk to you in a way that helps you think through projects. I try to help newer hires find someone who will really mentor them through the development process of growing as a physician as well as an educator or as a researcher, or whatever their interest is.
Q: What might explain the higher number of publications by physicians at the higher-ranked institutions?
A: Part of it might just be that the higher-ranked institutions have more of a machinery in place to help people grow. … It might also be that some of those programs are able to recruit people from more prolific residencies, where they're more likely than not to publish something as a middle or first author. Once you've figured out how to do that in residency, then it's a lot easier to replicate moving forward in your career. If you don't already have the mental map for how to do something like that, then it's a lot harder to get started.
Q: How can hospital medicine programs foster publication by newer physicians?
A: The University of Washington had a really interesting study on this, where they hired someone with a lot of research experience who had 50% protected time to coach people on how to publish. There was a worksheet that physicians would fill out if they were interested in applying for a grant or doing a review article or a study, and the coach would then look over their work and sit down and talk to them and help them identify the steps they needed to take. It was someone who wasn't a designated mentor for an individual, but a mentor for the department. They actually had really good results and saw a big increase in first-time publications, grant applications, and awards. It's sometimes hard, though, to justify funding for that type of position.
Q: How does grant funding factor in?
A: With grant funding, people already have more of a pathway built for them. Your university is really invested in making sure you're successful, because you're bringing in money. The people who aren't grant-funded run into barriers like, “How do I hire the statistician that I'm being told is $175 an hour? Am I going to pay out of pocket, or is the department going to pay?” Having dedicated support staff is really, really important to helping grow young academic faculty.
Q: Your results found fewer publications by women physicians. How should that be addressed?
A: One of my colleagues just coauthored a piece in the Journal of Hospital Medicine about women returning to the workforce after having a child, and I think that's the elephant in the room—not only that women have more career breaks, but there's also this assumption that if you're on maternity leave or coming back from maternity leave, you're not going to be interested in opportunities, which delays your growth and development as an academic physician even more. We need to think more about how to encourage and involve women without overcommitting them and still help their career to grow, even as they take time to have children and deal with the peripartum period. We also know that across the board, women in medicine are given more citizenship tasks, things like being on committees and doing interviews that often don't count towards promotion.
One other thing to mention is that we couldn't assess racial and ethnic disparities in our study or the implications for underrepresented minorities. However, I suspect that, similar to some of the general internal medicine studies that were done in the last 20 years, we're going to find a difference [in scholarly productivity] there as well. As we consider what to do for women, we probably need to also consider special interventions for underrepresented minorities.
Q: What other changes would you like to see?
A: It seems like publications are king, because that's really easy [as criteria for promotion]. You can type a name into PubMed and get results. That's quantifiable. It may make people really uncomfortable to have to deal with unquantifiable things on the promotion and tenure side. It seems to be a function of this system that's been used forever, but it doesn't work for everybody.
In the 1950s, much of the budget for the academic medical center came from grants, especially from the federal government, and now we've switched to most of the money coming from the clinical aspects. We've grown from having small clinical operations that mostly have staffing and teaching services to having these big clinical operations so that we can generate enough revenue to fund the research enterprise. In doing so, I think we've forgotten to update how we value the contributions of the clinician.
If you're not promoting based on actual value, if you're basing it on this value system of research alone, it's not equitable. If we're going to keep this system, we have to find a way to reward the people who excel as the clinician-educators, providing excellent care to patients, and allow them to be promoted along with the people who generate the amazing research that helps us improve health and well-being down the road.