R

E S E A R C H

E P O R T

Results of an Academic Promotion and Career Path

Survey of Faculty at the Johns Hopkins University
School of Medicine
Patricia A. Thomas, MD, Marie Diener-West, PhD, Marcia I. Canto, MD, MHS, Don R. Martin, MD,
Wendy S. Post, MD, MS, and Michael B. Streiff, MD
ABSTRACT
Purpose. Clinician educator faculty are increasing in
numbers in academic medical centers, but their academic
advancement is slower than that of research faculty. The
authors sought to quantify the magnitude of this difference in career advancement and to explore the characteristics of faculty that might explain the difference.
Method. In 1999, a questionnaire was administered to all
MD faculty at the rank of instructor and above (259) in
the Department of Medicine at the Johns Hopkins University School of Medicine.
Results. A total of 180 (69%) faculty returned questionnaires. Of these, 178 identified with one of four career
paths: basic researcher (46), clinical researcher (69), academic clinician (38), or teacher clinician (25). Career
path did not differ by age, gender, rank, years on faculty,
hours worked per week, family responsibility, or global
work satisfaction. After adjusting for age, gender, time at
rank, and work satisfaction, the odds of being at a higher
rank were 85% less for academic clinicians (odds ratio,

Medical schools are facing a number of

challenges, including their greater reliance on clinical revenue, increasing
competition for research funding, and
the need to reform medical education.
Each of these challenges has required
Dr. Thomas is associate professor; Dr. Canto is
assistant professor; Dr. Martin is assistant professor;
Dr. Post is assistant professor, and Dr. Streiff is
assistant professor, all in the Department of Medicine,
Johns Hopkins University School of Medicine; and
Dr. Diener-West is professor; Department of Biostatistics, Bloomberg School of Public Health, Johns
Hopkins University, Baltimore.

258

.15; 95% confidence interval, 0.06 0.40) and 69% less for
teacher clinicians (odds ratio, .31; 95% confidence interval, 0.11 0.88) than for basic researchers. Clinical researchers did not differ from basic researchers in the
likelihood of being at higher rank. Similarly, compared
with basic research faculty, the adjusted odds of being
more satisfied with progress towards academic promotion
were 92% lower for academic clinicians and 87% lower for
teacher clinicians.
Conclusions. Clinician educator faculty were less
likely to be at higher rank at this institution than were
faculty in research paths. Differences in rank may be
explained by lower rank at hire for faculty in these career
paths, time available for scholarly activities, or other
resources available to support scholarship. Retaining clinician educators will require further exploration of barriers to promotion inherent to these career paths and
methods of modifying these barriers.
Acad Med. 2004;79:258 264.

their faculty to increase their specialization, not only in medical content areas
but also in the broader missions of research, education, and patient care.
Most schools have responded by recruiting faculty dedicated primarily to the
patient care and education missions,1
and these clinician educator faculty are
Correspondence and requests for reprints should be addressed to Dr. Thomas, 9033 1830 E. Monument Street,
Baltimore, MD 21287; e-mail: pathomas@jhmi.edu.
For articles on related topics, see pp. 205213, 214
218, and 250 257.

often vulnerable in traditional systems

of faculty reward and recognition.2
A number of institutions have attempted innovative promotion systems
for faculty on academic career paths3,4
with variable success in improving the
recognition of clinician educators.5,6
By 2001, 91 North American medical
schools had faculty tracks in which clinical and teaching activities were the
primary criteria for promotion,7 although many of these were not tenure
eligible. Many approaches, such as the

ACADEMIC MEDICINE, VOL. 79, NO. 3 / MARCH 2004

recently suggested relative value units

for education activities, have not been
adequately evaluated to understand
their impact on faculty careers.8
The Johns Hopkins University School
of Medicine (JHUSOM) has examined its
promotion system multiple times during
the past decade and each time reaffirmed
the premise that the single-track system
best serves the needs of its faculty. Three
reasons for not developing multiple tracks
or specific criteria for promotion may be:
(1) a multiple-track system develops elitism within the faculty; (2) tracking faculty limits the opportunities for individual
careers to evolve over time; and (3) specific criteria actually constrain the ability
of promotion committees to recognize
creative and innovative scholarship. The
paucity of valid evaluation methods for
teaching and clinical practice was also
thought to decrease the rigor of the promotion process.9,10 As a result, the
schools published promotion guidelines
continue to emphasize scholarly publication and national and international reputation as the basis for promotion.11
A 1985 study of the promotion process at JHUSOM found no differences
in success of promotion for clinical and
research faculty12 and similar numbers
of publications in the two groups. The
study emphasized that most decisions
about faculty tenure were made by the
time the faculty members reached age
45. We doubted that clinical faculty
were able to maintain such publication
productivity in the current climate of
accountability in clinical practice and
questioned whether the earlier studys
findings remain valid. Discussions in our
community have suggested that if clinical faculty have not been promoted at
similar rates as research faculty, it is
because the clinical paths are newer to
the institution and populated by faculty
who may be less committed to scholarship because of age, gender, or family
responsibilities. The purpose of our
study was to identify Department of
Medicine faculty residing in different
career paths and explore characteristics

that may differentiate faculty in these

career paths, their global work satisfaction, and potential obstacles to scholarly productivity.

METHOD
Survey Development
We began developing the questionnaire
using a nominal group of departmental
faculty representing several divisions
who worked with previously published
definitions to write mutually exclusive
descriptors for four career paths.13,14
The basic researcher career track was
defined as those spending more than
50% of work time engaged in basic science research and having more than
50% of salary supported through extramural grants. The remainder of a basic
researchers time could be spent engaged in patient care, teaching, and
administrative activities. Clinical researchers were defined as being engaged in clinical research for more than
50% of their time and having more than
50% of their salary supported through
extramural grants. Less than 50% of
their effort was engaged in direct patient
care and as much as 10% could be devoted to administrative or teaching duties. Academic clinicians devoted
70% to 90% of their time to patient care
with teaching activities occupying the
remainder. The teacher clinician
pathway was defined as those spending
less than 50% of their time engaged in
patient care with the remainder devoted
to educational administration and
teaching. Based on these definitions,
faculty were asked to identify the singlebest descriptor of their career path.
Nine job satisfaction items were
drawn from other published surveys of
physicians job satisfaction as well as suggestions from the working group.1517
Other items requested demographic information. Faculty were asked to select categories for years on faculty, rank, years at
rank, years at previous rank, hours worked

per week, and shared family responsibility. The questionnaire (available from
the authors upon request) was pretested
for clarity by 12 faculty. After development, the questionnaire was mailed in
1999 to all full-time MD faculty in the
department at the rank of instructor and
above (268). The questionnaires were
coded for confidentiality and tracking.
Nonresponders received a second mailing and a final phone call and mailing.
Demographic data for the entire department of medicine and JHUSOM were
obtained from the faculty management
systems maintained by the dean of the
School of Medicine.

Statistical Analysis
We used the chi-square test to compare
the demographic characteristics of
respondents and nonrespondents and
assess bivariate associations between
categorical items. We used the KruskalWallis test to investigate differences in
Likert-scale items by career path. We
constructed a global satisfaction score
by averaging the possible responses to
the nine satisfaction items and used a
nonparametric test for trend to assess
correlations between it and items ranking likelihood and importance of remaining at JHUSOM.
We used ordinal logistic regression
methods18 using the proportional odds
model to assess the relationship between academic rank and career path
while preserving the ordinal nature of
the four level-outcome of academic
rank. The coefficients from the proportional odds model provided the log odds
of being at a higher rank versus a lesser
rank, as a function of predictor variables. We added the covariates of age,
gender, years at rank and global satisfaction score to the model. We performed a
separate ordinal logistic regression analysis to investigate the relationship between ordered four-level satisfaction
with progress in career goals toward academic promotion and career path.

ACADEMIC MEDICINE, VOL. 79, NO. 3 / MARCH 2004

259

Table 1
Gender, Age, and Rank Comparisons of Responders and Nonresponders to a Promotion and Career
Path Survey, Johns Hopkins University School of Medicine, 1999
% of Respondents by Career Path

Total

Basic
Clinical Academic Teacher
Department School
Researcher Researcher Clinician Clinician Nonresponders Responders Faculty Faculty
Male

74

75

82

76

82

77

Age 45 yrs.

70

61

63

60

57

63

Rank
Instructor
Assistant
Associate
Professor

9
41
24
26

7
35
33
25

29
32
26
13

8
48
24
20

11
34
29
25

Total (no.)

46

69

38

25

79

RESULTS
Of the 268 faculty surveyed, nine faculty had left the institution. Of the 259
faculty remaining, 180 responded (response rate 69%). Two faculty declined to identify a career path, so comparisons by career path are based on 178
responding faculty. We found no significant differences between 79 nonresponders and 180 responders by gender,
age, or rank. Table 1 shows the responders characteristics compared with faculty of the entire department and school
of medicine. There were no statistically
significant differences in age or gender
by career path.
Workload and Family Responsibility
The proportion of academic clinicians
working more than 60 hours per week
was greater than for other career paths
(see Table 2). Open-ended responses
indicated that academic clinicians averaged 1.4 months of general medicine
attending per year and 2.5 months of
subspecialty attending; teacher clinicians averaged 1.5 months of general

260

78

71

12
37
28
22

12
36
29
23

13
38
27
22

180

259

1508

medicine and 2.1 month of subspecialty

attending. Career paths did not differ by
marital status, number of children, or
shared family responsibility. Eighty-five
percent of respondents were married,
11% were single, and 4% divorced or
separated. Thirty-seven percent of all responding faculty acknowledged 30% or
less of shared family responsibility with
spouse, and 16% reported handling 60%
or more of shared family responsibility.
Men reported working more hours
per week than women faculty, but hours
worked per week did not differ for men
by career path (see Table 3). Women
faculty in different career paths, however, reported different hours worked
per week. Fifty-seven percent of women
academic clinicians reported working
60 or more hours per week. Although
more women than men reported higher
levels of family burden, the level of
family burden did not differ within each
gender by career path.
Work Satisfaction
The summary satisfaction score of the
nine work-satisfaction items as a mea-

sure of global work satisfaction

showed no difference in global satisfaction by career path. The global satisfaction score was correlated with the following questions: (1) How likely are you
to remain at JHUSOM in the next five
years? (2) How important is it for you to
remain at JHUSOM in the next five
years? (3) Have you considered other
positions in the past 12 months? Tests
for trend revealed significant (p .001)
positive correlations between satisfaction and responses to Questions 1 and 2.
Considering other positions was negatively correlated with satisfaction.

Rank and Progress in Promotion

Overall, years as faculty member, years
at rank, or years at previous rank did not
differ by career path (data not shown).
Table 4 shows the results of an ordinal
logistic regression analysis in which the
odds of being at higher rank were quantified for three of the career paths (clinician researcher, academic clinician,
and teacher clinician) using the basic
researcher path as a comparison group
and adjusting for the main effects of age,
gender, years at rank, and global satisfaction score. We also investigated age
gender interactions, but found they
were not influential and, hence, did not
include them in this final model. Compared with basic research faculty, the
adjusted odds of being at a higher rank
were 85% lower for academic clinicians
[odds ratio (OR), .15; 95% confidence
interval (CI), .06 .40] and 69% lower
for teacher clinicians (OR, .31; 95%
CI, .11.88).
Age and gender were also significant
(p .05) independent predictors of a
higher academic rank, but the effect of
age was greater than was that of gender.
Men were almost three times more
likely to be at higher rank were than
women, even after adjusting for other
factors in the model (adjusted OR, 2.76;
95% CI, 1.24 6.13). A higher global
satisfaction score increased the odds of

ACADEMIC MEDICINE, VOL. 79, NO. 3 / MARCH 2004

Table 2
Characteristics of Workload and Family Burden by Career Path for Department of Medicine Faculty,
Johns Hopkins University School of Medicine, 1999
% of Respondents by Career Path
Basic
Researcher

Clinical
Researcher

Academic Clinician

TeacherClinician

Hours worked per week

60
60

50
50

66
34

38
62*

52
48

Marital status
Single
Married
Divorced or separated

9
87
4

10
85
5

5
92
3

28
72
0

Number of children
0
12
3 or more

22
54
24

12
52
36

24
47
29

33
25
42

Share of family responsibility

60%
60%

76
24

83
17

77
23

90
10

Total (no.)

46

69

38

25

Characteristic

*Chi-square test comparison, p .05. Remaining chi-square comparisons were not significant (p .14 for marital status, p
.13 for no. of children, p .51 for share of family responsibility).

being at higher rank (adjusted OR, 1.97;

95% CI, 1.053.68). In contrast, years
at rank did not significantly influence
the odds of being at higher rank, after
adjusting for career path, age, gender,
and global satisfaction score. The likelihood ratio test for the baseline model
containing only the independent covariates for career path supported the
assumption of proportional odds across
the outcome categories of rank (6.04
with six degrees of freedom; p .42).
Table 4 also shows the results of an
ordinal logistic regression analysis using
the four levels of satisfaction with
progress in promotion goals as the outcome with career path, age, gender,
years at rank, and global satisfaction
score in the model. In comparison with
basic researchers, the adjusted odds of
being satisfied with promotion progress
were 61% lower in clinical researchers

(adjusted OR, .39; 95% CI, .17.89).

Similarly, the odds of satisfaction were
92% less for academic clinicians (adjusted OR, .08; 95% CI, .03 .23), and
87% less for teacher clinicians (adjusted OR, .13; 95% CI, .04 .42). In
this model, age, gender, and years at
rank were not statistically significantly
associated with satisfaction with promotion. However, a higher global satisfaction score was significantly associated
with increased satisfaction with promotion progress (adjusted OR, 69.0; 95%
CI, 26.95176.88).

DISCUSSION
To our knowledge, this is the first report
of a survey comparing faculty satisfaction and rank across career paths within
one institution. Sixty-four faculty mem-

bers, or 35% of respondents, identified

with one of the two clinician educator
paths in this department.
Although there was some belief that
academic advancement was less successful for these clinical faculty, this had not
been previously quantified in our system, presumably because there are no
formal career tracks that facilitated this
analysis. This survey did not attempt to
develop a full explanatory model for
slower promotion in these paths, and
the questionnaire did not collect information on publication records or incoming rank. We found a dramatic difference in academic advancement
between self-reported career paths,
however, despite adjustments for age
and gender. This result differs from a
previously published analysis of promotion success in this institution.12 Some
of this difference may be explained by
the differences in methodology used. In
the previous analysis, faculty who had
been placed into the promotion process
were compared with those who had left
the institution. A troubling concern is
whether clinical faculty are now more
likely to remain in the institution but
are stagnating in the lower ranks.
This is not the first study to suggest a
slower rate of promotion for clinician
educator faculty. Kelley and Stross14
found that defined tracks and criteria
still result in slower rates of promotion
for clinician educators. This observation suggests that delayed promotion is
not an institutional effect but inherent
in the career path, which requires time
for identification and development of
expertise in either clinical or educational fields and time to transition to
scholarly efforts from the usual job demands of clinical practice and teaching.
An institutional response to this finding
would be to identify other standards for
advancement in the early years of faculty appointment as a clinician educator. Our finding of significant differences
in satisfaction with progress in career
goals suggests that faculty are well aware
of their slower progress and that the cur-

ACADEMIC MEDICINE, VOL. 79, NO. 3 / MARCH 2004

261

Table 3
Characteristics of Workload and Family Burden by Gender and Career Path for Department of
Medicine Faculty, Johns Hopkins University School of Medicine, 1999
% of Respondents by Career Path
Basic
Researcher

Clinical
Researcher

Academic
Clinician

Teacher
Clinician

p Value*

60 hours worked per week

Men
Women

56
33

42
12

63
57

58
20

.261
.117

Married
Men
Women

94
67

88
75

94
86

79
50

.297
.334

60% share of family responsibility

Men
Women

13
60

11
38

10
83

0
50

.544
.319

Total (no.)
Men
Women
Overall

34
12
46

52
17
69

31
7
38

19
6
25

Characteristic

*Chi-square test.

Table 4
Results of Ordinal Logistic Regression Analysis on Promotion and Career Path for Department of
Medicine Faculty, Johns Hopkins University School of Medicine, 1999
Unadjusted
Career Path

OR

95% CI

Odds of being at higher rank*

Basic researcher
Clinical researcher
Academic clinician
Teacherclinician

1.00
1.18
.43
.80

.602.31
.19.96
.331.93

Odds of being more satisfied with

progress in career goals
Basic researcher
Clinical researcher
Academic clinician
Teacherclinician

1.00
1.20
.24
.33

.612.35
.10.57
.12.86

Adjusted
p Value

OR

95% CI

p Value

.63
.04
.62

1.00
.53
.15
.31

.241.20
.06.40
.11.88

.13
.01
.03

.60
.01
.02

1.00
.39
.08
.13

.17.89
.03.23
.04.42

.03
.01
.01

*OR is interpreted as the odds of being at a higher rank in a certain career path as compared to the odds in basic science
researchers, adjusting for age, gender, years at rank and global satisfaction score.
OR is interpreted as the odds of being more satisfied with progress in career goals toward promotion in a certain career path
as compared to the odds in basic science researchers.

262

rent single-track system has not eliminated a sense of elitism. The potential
consequences of failing to retain clinician educators in midlevel and senior positions at academic medical centers have
been well-described by others.19
We did not find disproportional representations of women in the clinical
paths or differences in hours worked or
family burdens that would explain potential outside influences on scholarly
productivity. Other barriers to promotion may exist, however, that are more
amenable to interventions. Studies of
women faculty may be helpful models in
understanding these barriers. A multiinstitutional study of women faculty reporting low satisfaction with career
progress found that women had less institutional support (e.g., research funding and secretarial support).20 Another
study noted that women faculty assigned a lower value than men did to
leadership and national recognition;
women faculty had the least time for
scholarly activity and the poorest understanding of promotion criteria.21
Similar themes have appeared in studies
of clinician educators. For instance,
one study found that physicianfaculty
who spent the majority of their time in
clinical activities had less time, mentoring, and resources for an academic career.22 So-called protected time is often
lost in the busy work week of clinical
faculty. Sheffield et al.23 found that clinician educators spent significantly less
time on scholarly activities than is designated for this work. Each of these
differences is a potential opportunity for
institutional intervention.
A major limitation of our study was
its focus on one clinical department
within one institution. Although our
respondents did not differ from nonrespondents demographically, the results
may have been affected by response
bias. Satisfied and successful faculty may
have felt less inclined to complete the
questionnaire. The questionnaire was
developed from some items for which
reliability was not tested, but most items

ACADEMIC MEDICINE, VOL. 79, NO. 3 / MARCH 2004

came from well-validated, previously

published instruments. The reliability of
the career path definitions has not been
tested. The use of the nominal group
helped to validate this section of the
questionnaire, however, and the consistency of our findings with other studies
showing a relationship between satisfaction and intention to leave the institution15,19 supports our belief in the content validity of the items.
We did not collect data on two factors that may have significantly influenced the rate of promotion. First, a
faculty members initial rank at appointment can impact the rate at which he
rises through the ranks. Such appointment decisions (e.g., instructor or assistant professor) are usually the discretion
of the division chief. We found that
29% of academic clinicians who responded were at the instructor rank,
versus 9% of basic researchers and 7% of
clinical researchers, which suggests that
academic clinicians are more likely to
receive lower initial appointments than
research faculty or reside at an entry
level for a longer period. Second, we did
not attempt to measure the scholarly
productivity of faculty. Without the
ability to assess impact and quality, the
working group felt that numbers of publications would be an inappropriate surrogate measure of scholarship, especially
for those in the academic clinician and
teacher clinician paths. We felt inclusion of other forms of scholarship24 was
also inappropriate because JHUSOM
has not formally recognized these forms
of scholarship in its promotion guidelines. In a system without explicit criteria, the measure of scholarship is continually evolving. Our goal was to
clarify the outcomes of this process.
The department of medicine is the
largest department at JHUSOM, and its
faculty demographics reflect that of the
faculty of the school at large. The challenges clinical faculty face in this department reflect those faced at other
institutions, and we feel our findings
could be generalized especially to other

single-track systems. These results add

to the literature supporting the magnitude of the disparity in reward and recognition of clinical faculty. Further research should continue to explore those
mutable predictors of career advancement and interventions that will diminish this disparity. Our discussions have
suggested potential interventions at several levels, including improved orientation of faculty to the promotion process,
mentorship and faculty development
that encourages scholarly activities such
as collaboration and dissemination of
work, institutional criteria for promotion specific to the career path of the
clinician educator, and representation
of senior clinician educators in the
evaluation of faculty work and promotion process. Each of these interventions should be explored and evaluated
for their impact on faculty satisfaction,
promotion, and retention.
The authors wish to acknowledge the work of
other members of the Clinician Educator Task
Force, especially Rita Falcone, MD, and Emma
Stokes, PhD, in the initial work of survey design,
and Drs. Michael Klag and David Levine for
reviewing earlier drafts of this manuscript.

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Teaching and Learning Moments

THE PROGRESS NOTE
Our hospital rotates students through some of the intensive care units. On the first day of my rotation, I was eager
to participate and was assigned to a patient that was admitted after a reported neurological event. I was told that while
the patient had focal findings last night, he was free from them now. An uncomplicated patient was not what I had
expected, but I would make the most of it.
I had all day to give the patient a thorough exam. Head to toe, fundoscopy to rectal, nothing went unchecked. He
passed the neurological exam, but struggled with the mental status exam. To my questions he quietly nodded, without
verbal response. Was he simply fatigued by my comprehensive evaluation or was something more going on? The CT
report outlined a focal area of ischemia in the left hemisphere at or about the angular gyrus. Armed with this new
information and having some recollection of my Step 1 neuro review, I pointed to his thumb and asked him which
finger it was and he looked at me blankly. I asked him to raise his right hand and I lifted my own to show him; he
returned by lifting his own right hand. I followed by requesting that he raise his left hand, but he lifted his right again.
Did he have a hemi-neglect? Or did he suffer from left-right confusion? I spent the remainder of the morning in the
library trying to put a name to my patients pathology. The description of Gerstmanns syndrome described my patient
perfectly: acalculia, dsygraphia, finger agnosia, and right-left confusion. I now had something relevant for my
assessment and fodder for discussion at rounds.
The residents took my exam and research as valid. I paraded many medical students to his bedside and proudly
presented the case as a classic example of Gerstmanns syndrome and a better example of how reading up on patient
presentation is the most effective way of learning. A neurologist was consulted to detail a baseline status. I eagerly
followed the neurologist to the bedside and waited for him to agree with my documented conclusion. Again, the
patient showed equal and full strength, brisk reflexes, good sensory perception, and no cranial nerve deficits. The
neurologist asked the patient to raise his right hand, and the patient raised his right hand. He asked the patient to
lift his left hand but the patient again raised his right. I was beaming. One of the patients relatives, who had not been
present during my earlier interactions with the patient, was also at the bedside and repeated the same question in
Russian; the patient vigorously responded by raising his left hand. Gerstmanns syndrome was looking less likely all
of the sudden. With translated questions, the patients exam became entirely benign.
After the neurologist documented his normal exam in the chart, I added my daily progress note: s/p neurologic
ischemic event patient shows dramatic improvement over previous exam.
ROBERT S. WILLIAMS, MD
Dr. Williams is a pediatric resident, Arkansas Childrens Hospital, Little Rock.

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ACADEMIC MEDICINE, VOL. 79, NO. 3 / MARCH 2004