The Johns Hopkins University School of Medicine
A "Letter of Experience" about
Faculty Promotion in Medical Schools
By Paul R. McHugh, MD
The author discusses major issues of faculty promotion in medical schools by describing the decision-making processes of the Professorial Promotion Committee (PPC) at The Johns Hopkins School of Medicine, a committee he chaired for several years. Perhaps the major dilemma of medical school promotion committees is how to define standards that encompass the several different excellences and highly diverse talents of their faculty. This dilemma prompts a search for a natural set of families of rank, admission to which can be defined clearly and operationally. The author discusses methods of doing this (via various faculty track systems) and the pros and cons of each; analyzes the processes by which the PPC assesses evidence of nominees achievements and attributes of scholarship; defines the three major career pathways at his school and explains the criteria used to evaluate nominees in each; outlines how the PPC evaluates individuals nominated for their excellence in teaching; and describes characteristics of nominees that may lead to their rejection. He makes clear that the decision-making processes of effective promotion committees are neither simple nor mechanistic and are sometimes difficult and problematic, and stresses the importance (in any promotional process, whether the setting be a medical school or a pencil factory) of institutional memory and of the committee's knowledge of leaders elsewhere whose generative contributions can be compared with those of nominees. The author concludes that the promotional process is not a simple survival of the fittest exercise but is a struggle to realize and foster an ideal of faculty quality to continue the high level of the institution s excellence and collegiality. Acad. Med 69 (1994):877-881.
I have written this essay as a letter of experience" about major issues of faculty promotion in medical schools. My views on these issues were gained during the 11 years, 1980 to 1991, when I was chairman of the Associate Professor Promotion Committee and then chairman of the Professorial Promotion Committee (PPC) at The Johns Hopkins School of Medicine (JHSM). For the sake of simplicity, I discuss what I have learned from both committees in terms of the latter one only, the PPC. That committee is a crucial step in the promotion process that begins with a department director's sending a nominating letter to the dean, who transmits it to the PPC, which initiates an evaluation of the nominee that if successful will be confirmed by the university's trustees.
I hope the observations below on the thinking and attitudes that inform the deliberations of the PPC in five major areas will be helpful if only as resources for discussion to academic faculties in other schools.
Tracks and Rankings
This first area is a troubles0me one that comprises the issues of tracks and rankings.
Promotion in academic rank is the usual way of recognizing scholarly achievement. But there is a major dilemma that must be struggled with by promotion committees in medical schools (in contrast to those in most other institutions of higher learning): with such a diversity of talents among the faculty, how can standards be defined that will encompass the several different excellences displayed by, for example, the biochemist, the gastrointestinal surgeon, the bedside teacher, and the gifted administrator? This matter has engendered a perennial search for a natural set of families of rank, admission to which can be defined clearly and operationally.
The method most often proposed is a division of faculty promotion along two or three tracks (e.g., academic, clinical, and tenure tracks). It has the advantage of separating basic scientists and research-oriented clinicians from the excellent implementers of medical and surgical practice among hospital-based physicians and administrators. These pathway distinctions at first blush seem the best way to move in institutions that have complicated and varied citizenries. The only problem is that people come to hate it. If they are placed in the clinical track, they often develop the feeling that they are members of a "second-class" group. This is sometimes encouraged by those on the academic track, who may suspect that rank in the clinical track is based on less rigorous standards or on local reputation rather than on scholarship and who disparage the contributions of colleagues in that track by comments such as, "He is a clinical professor." The multi- track system is a temporary solution to the diversity problem, but it eventually produces strong feelings of discrimination and neglect.
Another alternative method is a single track with multiple horizontal rankings instructor, assistant professor, associate professor, professor but then adding several further grades such as professor 1, 2, 3, 4, similar to the military s rankings, e.g., brigadier general, major general, five-star general, etc. This method leads to continuing agitation for promotion rather than a sense of resolution permitting the individual to get on with life without further preoccupation over title and prestige.
Johns Hopkins has minimized the problems described above by adhering to a single-track method of promotion with the traditional, unmultiplied horizontal rankings that describe both the responsibility and the achievement of the faculty, whether full-time or part-time. And there remain a few other natural ways of giving additional honor to a professor. These are the entitled chairs, personal professorships, and "distinguished" or "university professor" appellations that are usually conferred on individuals who direct departments and divisions. These titles represent pleasant honorifics distributed by the dean rather than additional steps in a career ladder.
The single-track model emphasizes the need for broad principles in defining the achievements and attributes of scholarship that advance an individual. Discussions over scholarship devolve into three fairly distinct aspects: activities that produce knowledge, activities that promulgate knowledge, and activities that apply knowledge. Promotion committees at Hopkins sense this hierarchy and employ it in their deliberations.
Evidence of Achievement
In assessing a nominee for promotion to professor, the crucial focus is on the first two kinds of activities just mentioned: the individual's abilities to produce and to promulgate knowledge. All appraisals are attempts to assess how an individual's various contributions have demonstrated these abilities. The problem for the PPC is how to represent the totality of that individual's contribution through the arrangement of available evidence. There are four aspects to this data-collecting process.
The first is simply counting the evidence. The counting of publications, patents received, programs (laboratories, clinical divisions or departments, institutes, etc.) launched and sustained, projects completed, grants awarded, students recruited, and courses carried provides the most obvious information to the PPC. This is the simplest and (sometimes wrongly) rather despised aspect of the process, but without some clearly enumerated products there can be nothing to assess.
The second aspect is weighing the count: discerning the importance of the contributions as wel1 as their rate of production. The value of a contribution in a published record is assessed by its effect on the field, its citation in other work, the impressions of peers, and their sense of its uniqueness. Primary authorship in periodical literature, monographs of a scholarly enterprise, and reviews in distinguished journals outweigh group authorship, edited books, and proceedings from conferences (although these endeavors are far from negligible). Other evidence of the impact of the published work that adds to its weight includes the translation of books into foreign languages, reprints of articles published in other journals, and recognition of outstanding papers identified as "citation classics."
The third aspect of data collection is direct appraisal from others of the contributions made by the nominee. Two important sources of information are the "pink sheets" from grant applications and the letters sought from consultants in the nominee's field of effort. The judgments from these sources carry considerable influence, as they are direct appraisals of the nominee's achievements by outside experts.
The final aspect of assessment is noting the objective ways in which the nominee's achievements have been acknowledged by others. This aspect is useful to ascertain how the individual has been valued in his or her own domain, whether that domain be large, as in surgery, or small, as in the study of the mast cell. Consideration is given to the nominee's election to editorships and memberships on editorial boards, committees, and councils; appointment to and chairmanships of National Institutes of Health study sections; election to and leadership of learned societies; honors and awards received (both internal and external); directive roles in national and international meetings where a responsibility for conducting, organizing, and evaluating progress in a field can be discerned; and finally, selection as a distinguished lecturer both within and outside the institution.
Career Pathways to Promotion
At JHSM the PPC tends to notice three career paths when identifying successful candidates for promotion to professor. Many individuals have been successful on all three of the pathways, but the paths can be distinguished from each other. I have chosen to identify these career pathways with the names of historical figures at Hopkins to personalize these achievements.
The first pathway, the William Welch pathway, is the simplest to describe and its endpoint is the simplest to define. An individual who succeeds to professor on this path is an individual who has made a significant discovery in the biological sciences and thus alters the basic foundations on which medicine is practiced. A significant discovery can be identified in many ways but if, like William Welch, the candidate has a bacillus named after him, the achievement is obvious. The absolute number of authored publications or books is not as salient an issue here, as the success tends to be clear from even a few articles because the face of medicine and of science related to medicine has been altered by the work.
The second pathway, the William Osler pathway, is one followed by a clinician-scholar who becomes an international authority on some significant issue in clinical medicine, such as a particular disease or therapy. The pathway is appropriately named because the role of Sir William Osler as a clinician, scholar, teacher, and author of the textbook The Principles and Practice of Medicine is vivid at Hopkins. Although the nominee need not be, like Osler, an authority on the whole discipline of medicine, he or she must be an acknowledged authority on some aspect of clinical medicine. Monographic publications on the subject should be acclaimed as work 1 hat defines the contemporary status of knowledge and identifies his or her contribution to it.
The nominee's work may have illuminated important aspects of the etiology, mechanism, presentation, or treatment of some disorder. For example, he or she may have designed a new surgical procedure that reduces subsequent impairments or have directed the evolution of a medical or surgical management method that enhances diagnostic, therapeutic, or prognostic capacities. Such work may relate a particular disease to other disorders or to emerging basic science knowledge.
The evidence of these achievements is found in the periodical literature, prominent textbooks, keynote addresses and leadership of conferences, and, where appropriate, monographic publications recognized as definitive presentations in the nominee's field of interest. The nominee's grasp of the subject is often found in his or her ease at communicating its nature to students. Objective evidence of this is found in teaching awards and in the career progress of the nominee's students.
The third pathway, the Henry Hurd pathway, rests on the demonstration that the individual has initiated or revitalized a major program of the institution such that scholarly activities of many people spring from his or her direction, choice of priorities, and vision. This pathway acknowledges that both the promotion of knowledge and its promulgation may depend upon facilities such as hospitals, libraries, computer centers, departmental divisions, and thus upon gifted and committed people who develop methods to enhance the powers of others in medicine and research. This pathway to promotion the most rarely employed and the most difficult to evaluate demands both the achievement of a successful administrative enterprise and its scholarly documentation.
Henry Hurd, the first director of The Johns Hopkins Hospital, was the exemplary individual who embodied such achievements. This pathway is characterized by two essential features. First, the individual must have been in office a sufficient length of time to establish a national reputation as an innovative administrative leader. As a result, these candidates are usually older than those who reach professorship on the other two pathways. Second, the nominee's administrative enterprise must have a scholarly documentation in published form that sets forth thoughtful solutions to contemporary administrative problems that can be employed as models by others. Such documentation is required to assure the PPC that the nominee in his or her role of directing and vitalizing a group of scientists, clinicians, and scholars is doing so according to a method and plan that relates to more than local circumstances.
Perhaps the issue that is most telling of the character of the PPC's deliberations is the evaluation of teaching in promotion decisions. The support of teaching is a major concern of all faculty since teaching is one of their traditional university responsibilities. Effective teaching depends upon communicative and analytic skills that vary widely in any group of faculty. Those who are skilled teachers are invaluable, since they inspire their students and colleagues.
Teaching excellence has a different salience in each of the pathways along which faculty can seek promotion. It is usually most prominent in the Osler pathway, although the PPC looks for and announces its contribution to academic excellence and leadership in the careers of all nominees.
What constitutes the elements of teaching upon which promotion to professor should depend, and which thus may be offered as examples to others? This question sparks extensive debate. The PPC's scrutiny becomes most intense when a nominee's teaching skills are announced as a prime characteristic of his or her role in the department. The usual information the PPC receives is how an individual teaches noting such features as eloquence, organization, liveliness, and the sense of good will students have toward such an individual. But for promotion to professor, something more is demanded.
The PPC looks for teaching that is challenging and progressive, expressed not so much in the "how" but in the "what" of teaching. The teacher must foster an active engagement over time with a broad range of students, promoting their sense of a discipline and contributing depth to their approach to it. For a professor, there must be evidence of this engagement beyond the goodwill of lecture auditors. We have at Hopkins some figures who are known as profound engagers of students at many levels undergraduate, graduate, postdoctoral in an advancing, illuminating fashion in the laboratory, at the bedside and clinic, and in the classroom.
The PPC expects to find evidence of four aspects of teaching excellence in those nominees whose department directors propose their promotion to professor primarily on the basis of their teaching. Scholarly evidence in the form of papers, chapters, or books that elucidate a substantial area in contemporary medicine; attractive evidence in the form of recruitment of talented people to specific endeavors and divisions at Johns Hopkins (and their subsequent success); peer evidence expressed in collaborative enterprises depicting a discipline in symposia, postgraduate courses, and textbooks; honorific evidence as in prizes and awards for teaching from both within and outside the institution. Such evidence provides a more compelling argument for a teacher's promotion than a local reputation or an accumulation of testimonials from students.
Reasons for Refusal
I now describe characteristics of nominees that may lead to their rejection in order to give contour to qualities that bring support from the PPC. But first one should lay to rest a common set of rumors about promotions. There is no set number of publications that is used as a standard. Some nominees have been promoted with fewer than 20 peer-reviewed periodical publications, and others with over 100 have not been promoted. Success does not demand unanimity in the opinions of outside referees, which would make nominees vulnerable to a blackball by letter. Many nominees pass with some dissenting consultant letters. The PPC is alert to aspects of personal animosity, conflict of interest, and hypercritical characteristics of some outside referees and discounts them.
The major hindrance to promotion is vagueness about the career achievement of the candidate. Each of the several pathways to promotion has its own particular markers of success. These should emerge clearly from the nominee's record and are helpfully emphasized in the department director's letter of nomination. Thus, individuals whose achievements are in the realm of basic research and new discovery (Welch path) should satisfy the PPC that they are the prime movers of important projects brought from their starts to logical ends. Also, once it is agreed that a work is itself a complete achievement, the PPC seeks assurance that it is not apprentice work, excellent though it might be, derived essentially from the leadership of the mentoring laboratory where the investigator began.
In assessing both the independence and the completeness of work there can be some uncertainty. However, the emergence of a person from the dominance of a mentor or from a group of successful and impressive collaborators can usually be identified by reviewing the candidate's record of publications and grant support. Also, independence is often clearly evident in the letters from within and outside JHSM that testify to the nominee's leadership.
For the clinician-scholar (Osler path), a sense of the person as an influential authority must emerge. The PPC seeks evidence that the nominee is an experienced, mature, and critical expert in a focused area of clinical study. This area of authority is often a particular disease but just as often it is a broad disciplinary area (e.g., epidemiology, genetics, immunology, transplantation, cardiology) in which the individual's teaching, clinical service, and publishing are progressive and have affected the thought and practice of others.
The published record is crucial for assessing nominees on this path, and with such coherent crystallization of the individual's knowledge and contributions, the committee will be uncertain of the extent of the nominee s scholarship and its influence on others even with local evidence of excellent teaching and clinical work. The most problematic nominee is one who is recognized as a fine clinician-teacher locally with a particular focus of expertise, but who has never brought together in published form a body of work that charts the extent of his or her personal experience and displays its role in shaping the thought or practice of the nominee's domain. The PPC turns to testimony from outside Hopkins to seek acknowledgement of the influence of the individual in the circle of scholars in his or her discipline. The testimonial letters often speak of the nominee's characteristics as a clinician-teacher and the high regard that others have for the individual as a physician. But absent from such letters may be any indication of the specific nature and form of the nominee s authoritative leadership in contemporary clinical knowledge.
It is from working with the PPC over such candidates that I have learned to champion the importance of advising clinician-scholars to produce monographic publications. These provide evidence of accrued and authoritative scholarship in an area and aid the committee in seeing how the nominee has defined and contributed to a field, enhancing its practice, clarifying its problems, or giving it a sense of direction. This is the kind of scholarship, critical reasoning, ant intellectual leadership characteristic of Osler himself, and without such monographic evidence I found that the PPC remained unsure of how the nominee was sustaining the enterprise of fostering progress in practice and thought that is at the heart of our institution. Such uncertainty may even question whether the acknowledged teaching skills are more like indoctrination than illumination.
The administrators-directors (Hurd pathway) are far and away the least common nominees and the most awkward for the PPC. Some members of the PPC question whether this pathway is a legitimate one for academic promotion and are restive when it is suggested. When this question arose during my time on the PPC, I reminded the inquisitor that managers and even umpires are elected to the baseball Hall of Fame. The PPC has promoted several individuals along this path with acclamation by the advisory board. Testimony from observers outside our school is crucial, particularly testimony that can give evidence that the vision and directions of a nominee are in fact being successfully employed at other institutions. Thus, to be considered significant, an administrative or organizational enterprise has to influence others in the solution of common problems in contemporary science and medicine. This influence must in part be exerted through published work.
Here I deal with a few other issues that are wrapped in the processes and spirit of our procedures.
The decision for promotion rests on a judgment of peers who, in committee, reflect on all aspects of the nominee's career. Thus the promotion of a nominee to professor is an evaluative opinion that does not emerge from some formula as though it were a matter of what is due, such as advancement in school grades or a rise in rank through attaining a given number of merit badges. Instead, this selection rests on a committee's judgment of quality built into such terminology as a leader, an authority, and a scholar. Such descriptors are built up from evidence from many sources and not simply extracted like an ingredient for a recipe.
Anyone with experience on committees becomes aware of the problems in employing them to make selective judgments. There is the difficulty of sustaining a consistent vision, particularly as committee membership changes. There is the awkward imbalance within the committee's discussions, where a strong negative opinion tends to outweigh several positive voices. There is a recurring tendency to simplify the judgment into a set of narrow factional expectations that dodges consideration of the diversity of excellence and achievement expressed in the various enterprises of nominees.
These are unavoidable tendencies of the committee method. The safeguards against them include the limitation of the tenures of the committee members, which means that experience with the committee eventually becomes widely shared in the senior faculty. Review of each decision by the advisory board and occasional visits from the dean to go over past committee actions and encourage certain directions and emphases are more immediate controls on the committee's judgments. The best safeguard is the ongoing series of discussions in repeated meetings of the committee, where several sources of influence on the committee's decisions become salient.
One source is the institutional memory, or repository of tradition, that identifies the expressions of excellence that have characterized the selections of the past. Often the attempt to articulate this tradition is presented in terms that are appropriately general so that the future is not restricted even as the past is not forgotten. In the committee, these matters emerge in discussion of recent exemplars of careers that resemble the nominee's and in attempts to identify pathways to promotion with historic exemplars.
A second and more immediate source of influence in promotional selection is the committee's knowledge of and acquaintance with leaders elsewhere who are seizing the scientific and technical opportunities in medicine today with vision and energy individuals whose generative contributions can be compared with those of nominees. It is in this fashion that individual achievement is identified and rewarded and also that trivial pursuits are contrasted with innovative and productive careers. These considerations demand a broad comprehension by the committee of current circumstances favorable to future progress in science and medicine.
There is nothing unique to medical schools about these two influences. Success in a pencil factory, a restaurant chain, or a sports franchise rest on an appreciation of identical linkages between tradition and the challenges of the present. As in all these and many other enterprises, selection through promotion cannot have a machinelike character, as though material were being processed, because the input characteristics are never the same. Each individual, even in the same discipline, reexpresses in some unique fashion the aims of a given professional life and career. The quality of these reexpressions must be compared with the internal vision of the institution and the quality of the achievements of others who are facing or have faced similar opportunities in each of the professional disciplines.
However, it remains true that comparison is at the heart of the PPC s work, and comparison is ever personal and problematic. The committee members, however, are on the side of the nominee and of his or her department director by virtue of their collegial relationships and mutual interdependence with all faculty. They do not see themselves as barriers to promotion but as interpreters of its aim to identify, reward, and so encourage activities and careers that can be emulated by others. The PPC does not like to reject individuals. In fact, it is the effort to find the strongest case for a nominee that slows the process of committee action most significantly.
The committee does promote the majority of nominees. Those whom they reject, they try to instruct. Those whom they support, they cheer, both within the meetings and afterwards, taking much pleasure in celebrating the accomplishments and personal qualities of each new professor. Certainly when I was chairman of the PPC, I enjoyed describing to the advisory board the careers and achievements that emerged from our review and long afterwards have rejoiced in my special, hidden acquaintance with the lives of these fine people that I gained by being a member of the committee.
All of this leads to a conclusion about an even more critical matter of the spirit behind the extra-departmental promotional process. Does it have the quality and simplicity of Darwinian exercises letting the "fittest" emerge from a process that does not bear scrutiny while we on this committee sit back and salute the victors? Neither I nor the committee s members think so. We see the promotional enterprise in more Jeffersonian terms, with an ideal of quality in mind and a continuing effort to articulate this ideal through the selections. The PPC hopes to show by its responses to nominees the many and various ways in which this ideal may be manifested. For we at Johns Hopkins are seeking to identify and encourage the best people we can find in any endeavor.
Promotion is something desirable on everybody's part. Desirable for the individual who achieves promotion, of course, but also desirable for the institution, particularly if it can be a means of directing the faculty along lines that are productive and bring success to everyone involved. From my experiences with the PPC at Johns Hopkins, I maintain that any effective promotion committee must strive to be both critical and friendly toward all individuals affected by the committee's actions, for this is the best way to make the kinds of decisions that will best sustain the excellence and collegiality of the institution s faculty.
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