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As a faculty member at Yale’s School of Medicine, I know this mostly applies to me — but it does not fully apply to me. As a “clinician-educator,” I have a pretty decent track record of scholarship and practice. However, were I to make the wrong move (hopefully not by writing this essay), I could be terminated from my position at the medical school. That would mean no longer seeing patients there, no longer teaching the resident pediatricians or medical students, and no longer conducting my research. The discontinuation of my hospital privileges would need to be reported on every form I ever filled out seeking new privileges elsewhere or even malpractice insurance. So I watch what I say, how I act, what I do, and what I teach.
I am not alone in lacking the luxury of tenure at a medical school. Tenure in this sector of higher education has typically accrued only to those at the top of the grant-funded research game — they bring money into the institution, and tenure is their de facto reward. In fact, according to data from the Association of American Medical Colleges, only 12 percent of all medical-school faculty members have tenure (an additional 13 percent are on the tenure track). The other three-quarters bear the majority of the teaching and clinical missions of the schools, but they must monitor their actions closely, as I do.
Tenure protects academic freedom — it provides faculty members with security so that if they speak truth to power, either on the narrow scale of their own institution or on the wider national scene, they will be safe from repercussions. For example, while many of the medical-school faculty members at my Northeastern urban institution joined residents and students at the White Coats for Black Lives demonstration, in the summer of 2020, there were colleagues across the country who did not feel they could join in for fear of reprisal. In addition, faculty members may fear repercussions for teaching about politically controversial subjects, such as the medical sequelae of gun ownership, the effect of racism on children’s development, or the importance of social determinants of health, though these discussions are often necessary to develop the skills of nascent physicians.
Of course, any egregious violation of professionalism should be pursued. Someone who abuses colleagues or the staff or patient trust, or who steals, or who has undisclosed conflicts of interest should absolutely be held to account. But not professors who are doing their best to speak up for students, intercede for patients, or report misbehavior — even if that is not what the hierarchy wants to hear.
Not every profession has tenure — it is pretty much limited to the educational sphere. The American Association of University Professors ratified an early declaration on tenure at its second meeting, in 1915, and evolved principles in its 1940 Statement of Principles on Academic Freedom and Tenure. Generally, people get tenure based on academic achievement, including not only research and grant funding, but also excellence in teaching, service to the institution, and academic visibility. The balance of those requirements can vary among institutions, and among professions. For example, in law schools, while 21 percent of faculty members are on a traditional tenure path, 8 percent are on a “clinical” tenure track, with different expectations for research and scholarship.
Nationally, more and more physicians are being employed by larger and larger hospital systems, including academic medical centers. Most of those physicians are not directly involved in the educational mission — they don’t participate in academe. But a core group of academic physicians at every medical school are educators and scholars of education, yet hold essentially probationary positions. Isn’t it time to expand medical-school tenure to include not only the grant-heavy researchers, but also those who attempt to impart patient-centered, ethical, and equitable training to our future physicians?