'Full-time' faculty: an evolving construct?

In another publication I recently reviewed "The Academic Practice of Otolaryngology." (1) That article makes the case that academic practice is a state of mind, not a source of employment. It is possible for all of us to remain academically and intellectually vital throughout our practice careers, regardless of whether we are employed by universities or even have university affiliation. Throughout the history of otolaryngology, many of our most important innovations and discoveries were made by private practitioners. Only a few great names in otology were full-time academicians and, for example, at the House Ear Institute no one was. Nevertheless, during the last two or three decades, there has been a shift of academically active physicians (otolaryngologists and others) toward a university employment model, partly because of changes in the economics of medical practice. Previously, even many "full-time" academicians were really geographic full-time physicians who practiced at a university but whose economics depended almost entirely on a private-practice model. This included even department chairs at venerable institutions such as the University of Michigan, through the time of Dr. Walter Work in the 1970s. This model was successful partly because of the altruistic culture of volunteer faculty and the graciousness with which they were integrated into teaching programs. Integration of volunteer faculty from numerous practices also enhanced resident training through more diverse exposure than is generally available through a single group, even an academic department. Although that model has been virtually abandoned recently at many institutions, it has not been forgotten; and it may warrant reconsideration.

Institutions throughout the United States and elsewhere are struggling with the economic pressures of healthcare delivery and education. While there was a time when it was possible to provide substantial support to medical schools through excess income from physician faculty, such heady days are gone in most places. Recently, most academic institutions in the United States have responded to such pressures by trying to minimize or eliminate the role of volunteer faculty in order to maximize the practice plan's market share, influencing clinicians to either leave universities or become full-time, salaried employees. Although this strategy has worked at some institutions, it has resulted in "red ink" for more than a few practice plans, particularly in some of the nonsurgical disciplines. Moreover, it has forced many experienced clinicians and teachers to abandon institutions whose reputations they helped establish, often taking their patients and prestige with them. This situation naturally leads one to wonder whether there is a sensible alternative to the current trend toward "full-time or no-time" academic practice.

One solution may be a shift back toward the model that worked so well throughout the first three-quarters of the 20th century. Many of us over 50, and most otolaryngologists over 70, were trained by dedicated clinical teachers and scientists who were committed to resident and medical student education, who amassed an impressive record of advances in the field, and who did all their teaching on a volunteer or "geographic full-time" basis. Most paid no "dean's tax," but they also charged institutions little or nothing. They were responsible for their own economic success or failure and never generated any red ink for an institution. While changes in the economics of private practice have made this model a bit more challenging, the trend toward minimizing or abandoning its potential contribution to academic programs does not seem to be the most sensible solution. It is time for us to reassess the structure of our academic faculties (not just in otolaryngology, but in all fields) and to reconsider models that combine full-time, salaried clinical and research faculty (perhaps in somewhat smaller numbers) more effectively with volunteer faculty whose academic status and title are determined by their academic performance, not by the source of their income.

In these days of limited resources, it makes little sense to squander clinical and academic expertise that used to be incorporated into our educational programs at little or no cost to academic institutions. It was the model that got us where we are. While the pendulum may never swing back to a complete dependence on this model (and probably should not), it is time to consider whether the pendulum has swung too far toward the other extreme and to open our minds and our institutions to a structure that incorporates the best of both approaches to medical education.

Reference

(1.) Sataloff RT. The academic practice of otolaryngology: Philosophical and practical perspectives. Ann Otol Rhinol Laryngol, 2006;115:403-7.

ROBERT THAYER SATALOFF, MD, DMA 

Editor-in-Chief

EAR, NOSE & THROAT JOURNAL