Why Opportunities for Tenure Matter for Minoritized Faculty in Academic Medicine
================================================================================

* Claudia Alvarez
* Deyanna M. Boston
* Lauren W. Norman
* Brett A. Thomas
* José E. Rodríguez
* Kendall M. Campbell

## Abstract

Academic medicine continues to characterize the experiences of Black and other minoritized faculty in medicine to enhance their careers and promote their advancement. An issue of discussion is tenure and its role in the advancement and retention of this group. Tenure is a sign of national presence, command of an area of study, and can demonstrate support from the institution in terms of permanent employment, eligibility to apply for awards, sit or vote on certain committees or qualify for certain leadership opportunities. Anecdotally there have been reports that tenure is a thing of the past that has lost relevance prompting some to end tenure in their institutions. Reasons for this are complex, however the literature does not include minoritized faculty as a reason for the need to revise or eliminate tenure and tenure earning tracks. The authors discuss 3 reasons why Black and other minoritized faculty should be afforded the opportunity to achieve permanent status in their academic health centers. They include histories of being denied freedom, having information concealed or being giving false information, and being denied permanent academic employment status.

*   Diversity
*   Family Medicine
*   Health Disparities
*   Job Tenure
*   Medical Faculty

## Introduction

Academic medicine continues to characterize and define the experiences of minoritized faculty who are underrepresented in medicine (URiM) in attempts to improve their faculty experience and promote their advancement.1,2 This work not only involves providing mentorship and growth opportunities for this group, but also involves examining academic environments to address and dismantle systems that advantage some and disadvantage others.3 Antiracism initiatives, faculty development opportunities, society-directed initiatives, and mentoring programs have strengthened opportunities for minoritized faculty success.3⇓⇓–6 Faculty who are underrepresented in medicine, or minoritized, include people who are Black or African American, Latinx (Hispanic or Latino), American Indian and Alaska Native (AIAN) and Native Hawaiian and other Pacific Islander.

Tenure and its role in the advancement and retention of the minoritized faculty member is an issue of discussion in some circles of academic medicine. There have been no contributions to the literature that discuss the importance of tenure for this group and whether they should pursue tenure as faculty in academic medicine. There is evidence, however that minoritized faculty are tenured and in tenure earning tracks less often than their majority counterparts, and that they are concentrated in lower ranks in academic institutions.7,8 It could also be argued that family medicine physicians are less likely to be tenured or in tenure earning tracks. According to 2022 data from the Association of American Medical Colleges, of the 23,436 tenured faculty, only 353 were family physicians, with around 11% of those family physicians identifying as racial/ethnic minoritized physicians, being 6.5% Hispanic, 3.7% Black and 0.6% Alaska Native.9

Tenure has been longstanding in education, dating back to 1915, recognizing creativity and academic freedom of faculty with the intent of protecting faculty from being fired.10 It is a sign of national presence and command of an area of study and can demonstrate support from the institution in terms of permanent employment. Not only that, tenure status can bring with it eligibility to apply for otherwise restricted awards, sit or vote on certain committees or qualify for certain leadership opportunities. There have been approaches taken to broaden criteria through which tenure has been awarded, to recognize different types of scholarship.11 The literature shares steps to achieving tenure in comparative professions.12,13

Anecdotally there have been reports that tenure is a thing of the past that has lost relevance prompting some to end tenure in their institutions. Walling and Nilson found that over the time period of 2006 to 2016 there was an increase in nontenure tracks by more than 60% and a decrease in tenure tracks by 0.8% in clinical specialties.14 An issue with tenure comes when faculty who have earned tenure become much less productive, and yet may earn salaries out of proportion to their productivity. Because of shrinking budgets and the fact that these faculty take up office and lab space and may be paid enough to onboard 2 early career faculty, tenure has come under review.15 In addition, in reimagining how tenure is structured, guaranteed financial protections have been going away due to high salaries of physicians.10 In addition to this movement, there have been discussions to broaden activities counted toward tenure and promotion looking to consider committee service, community service, leadership roles, and scholarship in various forms beyond peer reviewed publications alone. Even though there may be mixed feelings about the current role of tenure in academic health systems, recognizing and rewarding excellence in education, research, and clinical care remain important.16

However, the literature does not include minoritized faculty as a reason for the need to revise or eliminate tenure and tenure earning tracks. In fact, historically minoritized physicians, and in particular Black physicians, were thought to be incapable of serving outside of sanitation clinician roles.17⇓–19 Because Black physicians were pushed away from scholarship and research, we believe this group has been largely denied the opportunity for permanent status. Because tenure may be associated with leadership positions, a greater comfort level with employment, and increased salary, it is important to consider tenure a tool that may bring equity to Black and other minoritized faculty in academic medicine.7 Discussions about the future of tenure should consider the historic injustices done to underrepresented and minoritized groups so that decisions are equitable.

Whether one believes that tenure should be abolished or not, there is truth that tenure provides a level of academic accomplishment that we want in our academic centers. We want sustained excellence, contributions to the literature that improve health outcomes, solutions to complex problems in health care, and novel ways of educating learners. In this perspectives article, we discuss 3 reasons why Black and other minoritized faculty should be afforded the opportunity to achieve permanent status in their academic health centers.

## History of Being Denied Freedom

Due to a history of racism, slavery, and the denial of educational rights, academic freedom is part of the freedoms Black individuals are due. Hence, academic freedom for Black and minoritized faculty should not only be valued by institutional leaders but should be supported and encouraged. By academic freedom, we are talking about freedom of expression of professional interests through research, manuscripts, presentations or curriculum development without fear of reprisal of institutional leadership.20 In 1910, the opportunity for Black physician faculty to make significant contributions to medicine and join the physician workforce was hindered through the Flexner report which led to the closing of several historically Black medical colleges.17 The Black schools that were left open were left open to train Black doctors to take care of sick Black people to decrease opportunity for disease transmission to white people.21 These closings not only impacted the production of Black physicians, but also decreased the opportunity for them to become tenured faculty. The award of tenure allows Black and minoritized faculty to share issues that impact their experiences in academic medicine. In addition, academic freedom can promote psychological safety, encouraging opportunities for faculty growth and development in a group that has been marginalized and historically not free.3

Heavy clinical demands, limited mentorship, increased committee and community service, and low institutional expectations can impede the ability of minoritized faculty to achieve tenure.22⇓–24 Because of these examples of minority taxation and gate blocking of minoritized faculty, senior leaders must limit these distractions to ensure that this group experiences psychological safety, sponsorship and mentorship on the path to career advancement.1,3,23

## History of Concealing or Giving False Information to Minoritized People

Historically, information has been kept from Black and other minoritized individuals.25,26 Black people have been prohibited from learning to read, write and attend institutions of higher learning.27 Being vague about the tenure requirements and process has historically been the experience of faculty across disciplines and we believe a bigger part of the Black and minoritized faculty experience.28,29 For minoritized faculty, this impacts understanding and fulfilling the requirements for tenure, ultimately resulting in the lower rates of promotion.8,30

In an article published nearly thirty years ago by the American College of Physicians, it was recommended that there be wide dissemination of tenure and promotion guidelines to junior faculty including women and minoritized faculty.25 Unfortunately, experiences of the authors have shown that some are still facing instances where promotion and tenure guidelines are not clearly communicated, from being unaware of tenure and promotion requirements and their location, to being unaware of the career track into which they were hired.

Departmental and institutional leaders should adhere to promotion and tenure policies without changing criteria on short notice because of personal desires. An example would be modifying the numbers of manuscripts required for promotion because of wanting a minoritized faculty member to serve on a committee or taskforce. Moving goal posts for advancement without clear explanation or purpose can be viewed as manipulative. These actions could be seen as attempts to create pseudoleaders through manipulation and self-serving advice.31,32

At the time of hire, institutional leaders should share where promotion and tenure criteria can be referenced, specifics about career tracks available, and pros and cons of each track as it relates to faculty career interest and growth potential. This is a must for all faculty, not just those who are minoritized or underrepresented in medicine. Allowing faculty to choose the career track that they feel best fits their interest is a way to promote inclusivity and personalize decision making that can benefit the success of the minoritized faculty member as well as the department and institution. Included in this discussion should be the option of tenure earning tracks and what tenure provides at that specific institution.

Limited sharing of how to advance within the organization and confusion and lack of clarity around promotion and tenure guidelines and process could be considered by some a racialized act given the history of how minoritized groups have been marginalized and excluded.33 Minoritized faculty have historically been given more patient care and community engagement responsibilities than nonminoritized peers, which reduces the time they have to actually fulfill promotion and tenure requirements set by their institutions.23,34 Denying Black and other minoritized faculty the opportunity to achieve tenure status can be viewed as an act of social control in place to maintain the white status quo.35 Part of institutions fully embracing and implementing inclusive and equitable hiring and advancement practices will require the full disclosure of the promotion and tenure process to all faculty to benefit their career development and for the benefit of the department and institution. This history should prompt institutions to clearly define, fully disclose and adhere to promotion and tenure process and guidelines.

## History of Being Denied Permanent Academic Employment Status

Permanent status confers opportunities for enduring contributions to the field of medicine. Because minoritized faculty do more health disparity research and are interested in research needs of minority and under-resourced populations, permanent status has the potential for even more innovations and advances in science to help improve the lives of patients, families, and communities.22 This would be a departure from the clinically-focused job of providing care which we were historically permitted and relegated to do. Minoritized faculty have talent beyond just the provision of clinical care and have contributions to make to the education and research missions of our institutions. Supporting educational development, research, and scholarship for this group is a must for academic institutions. This development can be considered the nidus for the development of enduring contributions like developing curricula and ongoing research and scholarship in an area of interest.

Permanent status is an accomplishment that may be denied to some minoritized faculty with the decrease of tenure tracks in academic medicine.36 When minoritized faculty achieve permanent status they can become an attractive force to recruit, retain, and support other diversity in the health care workforce such as medical students, resident physicians and junior faculty.36 Their permanent status enhances their ability to gain institutional knowledge and develop the necessary skills to best orient other minority physicians in their network that are joining the institution.

Because of institutional racism, the minority tax, pseudoleadership and gate blocking, determining if a minoritized faculty member meets criteria for permanent status should be approached equitably with national peer review. A newly defined term, pseudoleadership occurs when early career minoritized faculty are placed in leadership positions without the proper training, resources or institutional support to be successful in the role.27,28 Minoritized faculty need to be assured that there is a mechanism to capture excellence in clinical, educational, and research endeavors and that the institution will provide resources and an equitable experience to facilitate career growth and success. It must be clear that excellence in committee service and community work has to be translated to enduring products that align with department and institutional missions to be considered for permanent status.

## Conclusions

In this manuscript we have shared from a historic perspective why opportunities to achieve tenure matter for Black and other minoritized faculty. We have underscored why academic freedom should be part of the freedoms that minoritized faculty experience, how a history of concealing and providing false information continues to be a problem for minoritized faculty, and why achieving permanent status should be an option. This article is a call to action to academic leaders who define faculty career tracks to offer such tracks as options to all faculty, including those who are underrepresented or minoritized in medicine.

## Notes

*   This article was externally peer reviewed.

*   *Funding:* This work was funded by the American Board of Family Medicine (ABFM) through a grant to the Society of Teachers of Family Medicine (STFM) to fund the Leadership through Scholarship Fellowship.

*   *Conflict of interest:* None.

*   To see this article online, please go to: [http://jabfm.org/content/37/3/497.full](http://jabfm.org/content/37/3/497.full).

*   Received for publication May 31, 2023.
*   Revision received September 19, 2023.
*   Accepted for publication September 27, 2023.

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