Tenure is declining in U.S. medical schools. Could this threaten academic freedom

For more than a century, tenure has served as a bedrock principle in American academia.

When it was first formalized by the American Association of University Professors (AAUP) in 1915, its primary purpose was to guard the right of professors to research and teach about subjects in their areas of expertise without influence or fear of retribution from university leadership, donors, political figures, or any other entities that might try to suppress or control scholarship.

But, in recent decades, tenure appointments at universities have declined. The percentage of full-time, tenured faculty at universities has gone from 39% in 1987 to 24% in 2021, according to the AAUP.

The decline has also been dramatic at U.S. medical schools, according to a recent analysis published in Academic Medicine, a peer-reviewed journal of the Association of American Medical Colleges (AAMC). The percentage of full-time PhD faculty who were tenured or in tenure-track positions in basic science departments at U.S. medical schools decreased from 78% in 1982 to 64% in 2022. In that same period, the percentage of full-time basic science faculty with non-tenure-track appointments nearly doubled from 17% to 32%.

Similarly, clinical faculty appointments to tenured positions have declined in the past 40 years, the analysis found. The percentage fell from 59% in 1982 to 18% in 2022.

This may be attributed to a combination of factors, including medical schools' financial models and higher salary structure compared to the rest of academia as well as growing ranks of clinicians with faculty appointments who have fewer teaching and research responsibilities, according to the analysis.

Health systems with a greater emphasis on clinical care may not see the value of investing in tenured academic appointments, and newer medical schools, especially those not associated with a university, are less likely to adopt the tenure structure of academia, according to the article.

This trend is concerning to some faculty members who worry this could erode academic freedom, particularly in an increasingly polarized political climate.

"We talk about tenure all the time as this important structure by which academic freedom can be guaranteed to speak out on matters of importance in the classroom and extramurally," says William T. Mallon, EdD, senior director of strategy and innovation development at the AAMC and lead author of the recent analysis who has studied tenure in academic medicine and higher education for 25 years. "All true, and yet fewer faculty have the benefits of tenure."

Tenure can be an essential protection for faculty members to feel confident to speak up within their health systems when they disagree with the administration, says Vincent Pellegrini, MD, an orthopaedic surgeon and a professor of orthopaedics and the Dartmouth Institute for Health Policy and Clinical Practice, vice chair for Education and Research Affairs in the Department of Orthopaedics, and chair of the Faculty Council at the Geisel School of Medicine at Dartmouth in Hanover, N.H. He has noticed his fellow faculty members self-censoring.

"There's increasing reluctance for people to speak out," Pellegrini says. "The provision of tenure - in its earliest form - was done to preserve and protect the notion that we want faculty to be able to speak out even - and especially - when they had a different opinion. Different opinions are what made the classroom interesting, stimulated science, and allowed people to question the dogma."

Tenure and academic freedom

In its 1915 Declaration of Principles, the AAUP laid out the definitions and principles of both academic freedom and tenure, which have been revised and reinterpreted several times, most recently in 1970.

It recognizes academic freedom as having four main components: freedom in teaching; freedom in research pursuits; freedom to speak up on institutional governance matters; and freedom to speak as public citizens.

Tenure was designed to protect these freedoms by providing accomplished scholars opportunities for stable employment that could not be easily removed if the scholar's academic pursuits were unpopular or unprofitable. According to the AAUP, tenure should be available to all faculty after a probationary period of no more than seven years and, once tenured, employment should only be terminated for adequate cause and with due process. Though every institution establishes its own tenure policies, most require the tenure-eligible faculty member to demonstrate significant academic achievement in publication of research, excellence in teaching, service to the institution and/or the community, and in some cases, the consistent ability to secure grant funding for their research.

The purpose of preserving these principles is not to further the interests of individual professors or institutions. Rather, it is to benefit the common good. "The common good depends upon the free search for truth and its free exposition," according to the AAUP.

But many universities have been moving away from tenure-based systems in the past few decades.

"[There's been an] erosion and decline of the tenure system," says Henry Reichman, PhD, former chair of the AAUP's Committee on Academic Freedom and Tenure, who has recently written two books on academic freedom. "In the 1970s, two-thirds to three-quarters of all teachers in higher education were - if not tenured - were eligible for tenure. Today the proportion is reversed, only a quarter to a third are in the tenure system at all."

Reichman says that, in the absence of tenure, most faculty members can be dismissed easily and with little recourse if university administration decides not to renew their contracts, making them vulnerable to attacks on their academic freedom. This erodes not only the faculty members' scholarly freedom, but also the strength of faculty-shared governance of the institution, another bedrock of academia.

Though medical schools share a broader academic mission with the rest of higher education, their entwinement with clinical practice sets them apart. In addition to the research and education missions of academia, there is the added responsibility of patient care. This means many faculty are also practicing clinicians and receive the bulk of their income from this work. Still, many medical schools also employ basic science faculty whose primary work is in research. Often, these scientists are responsible for raising some part of their salary by applying for grants to fund their labs.

Tenure in academic medicine

Over the past 20 years, many medical schools have adapted their tenure policies to make them more feasible in light of financial constraints, and to meet the changing needs for medical school faculty. Some have extended their probationary periods beyond the AAUP's recommended seven years and instituted tenure-clock stopping (most often used for family leave), and many have limited or eliminated the financial guarantees of tenure. Many medical schools now offer varying types of career paths besides tenured and tenure-track appointments.

At the University of Wisconsin (UW) School of Medicine and Public Health, for example, just 17% of the medical school faculty is tenured.

For most of the clinicians it employs, jumping through the hoops required to achieve tenure just didn't seem worth it, explains Peter Newcomer, MD, chief operating officer at UW Health. "Most physicians come from the clinical mission," he says. "Just getting your tenure pay isn't going to compare."

At the same time, Newcomer says that UW Health sees the value of academic medicine's mission and the desire for faculty to have protected time for research, even if they aren't on a tenure track. Their solution was to create a "middle track" that allows faculty members to have more than half of their time protected for research and educational purposes, while still spending a portion of their time providing clinical care, and without the "publish or perish" pressures of pursuing tenure, he explains.

The flexible approach has helped the system recruit researchers and clinicians and further the institution's mission to serve the community through innovation. Still, as a physician in administration, Newcomer finds himself having to defend the academic mission of the institution to business administrators, donors, and politicians who have less experience in academia and challenge the value of spending money on the research and education components of the mission, especially when it comes to tenure.

"Carrying that message, internally and externally, of why we care about tenured faculty, it's a challenge," Newcomer says."In the back of my mind, I never forget how important education is in an academic medical center. We do need that for our own future. How do you get the next doctor, the next practitioner? You have to get them trained … It is about the symbiotic relationship between the health system and the medical school: Wesupply the clinical environment in which they work so they can do that education and research."

Academic freedom in a polarized political climate

While tenure has been declining over the past several decades, the current environment in which many clinical faculty are employed by large health systems, combined with a polarized political climate, may make it more important than it's been in the past, some say.

"Academic medicine is not immune to academic capitalism and corporatization of medical education," says Guadalupe Federico-Martinez, PhD, a former assistant dean of faculty and academic affairs who has studied university systems and faculty behavior for nearly two decades.

As health systems face increasing financial pressure and adopt more business-driven approaches to the clinical enterprise, the academic freedom of faculty - particularly untenured faculty - could be threatened, Pellegrini adds.

"It's become a big business," he says. "The education and medical school component of that partnership [with health systems] is being overshadowed by the business of the clinical enterprise. The principles of academia, education, and scholarly work have been diluted out by the increasing imperative to generate a margin."

Some medical school faculty are feeling pressure from within their institutions to suppress their opinions that might be viewed as political, despite academic freedom protecting a faculty member's right to speak publicly on controversial issues.

"People speaking out on political issues have been ostracized or penalized," says Aviad Haramati, PhD, a professor of Integrative Physiology and Medicine and director of the Center for Innovation and Leadership in Education (CENTILE) at Georgetown University Medical Center in Washington, D.C. "At many institutions, if you're not towing the line, you're at risk."

Haramati, immediate past chair of the AAMC'sCouncil of Faculty and Academic Societies (CFAS) and a former member of the AAMC Board of Directors, believes medical schools must consider restoring the value of tenure if they are to preserve the integrity of their academic institutions.

Reducing tenure "ultimately stifles faculty," he says. "I see it especially in clinical departments. People are less likely to speak out on controversies, then leaders only hear one voice, their own voice … There's a danger of creating an echo chamber as opposed to benefitting from a community of diverse thinking."

The threat can also come from outside the institutions' walls.

In recent years, politicians and state legislatures in the United States have increasingly sought to limit academic freedom in public institutions of higher learning.

According to the Academic Freedom Index Update 2023 published by the Friedrich Alexander Universität Institute of Political Science in Germany, which seeks to analyze threats to academic freedom across the globe, the United States ranked below more than 70 countries and is declining on a number of measures.

This has included a rash of bills proposed in state legislatures seeking to influence or restrict what is taught in universities. Some of the bills, including one that recently became law in Indiana, include measures that could weaken tenure.

The political landscape has made tenure more relevant to medical school faculty than it has been in the past, says Arthur R. Derse, MD, JD, director for the Center of Bioethics and Medical Humanities and a professor of bioethics and emergency medicine at the Medical College of Wisconsin and chair-elect of the CFAS administrative board.

"In the modern medical school, there are a number of faculty working in areas that have become politically sensitive," Derse says. "Legislatures and political actors today are much more interested in making sure their particular view about medicine and science predominates, sometimes in conflict with the knowledge, experience, and considered judgment of medical school faculty … These issues that are now in the court of public opinion have really changed the environment in which faculty do research and practice in their area of expertise."

Beyond tenure

Federico-Martinez believes that, with tenure showing little sign of resurgence, it's time for medical school administrators to find innovative ways to remain competitive with private industry. This includes finding other avenues to preserve academic freedom.

"How do we still encourage physicians and trainees to become and remain faculty members and feel safe and protected without tenure - to research, study, and have discourse around sensitive topics, such as women's rights, gender-affirming care, and DEI as Mallon and Cox point out [in their analysis]?" she says. "How does this lack of protection influence the future generations of physicians while they're pushing the envelope on innovation and topics that are not only sensitive for our nation, but remain as global issues?"

So far, the answers to these questions are elusive.

"People have been talking for decades about alternatives to tenure that protect academic freedom," Mallon says. "But that's all it's been - talk. And meanwhile, the vast majority of faculty in the academy don't have the protections of academic freedom that we laud as an essential principle."

Pellegrini says that change will have to come from the leaders of academic medical institutions.

"Leaders need to have been raised on academic medicine to respect what the academic side of the house brings to the equation," he says. "The vision should come from people who have practiced medicine in an academic setting and understand the value academics bring to clinical practice."