Chair's Column: Recruitment to Academic Medicine in the Department of Medicine

The anxiety among our trainees – particularly those wishing for a career in academic medicine – about the likelihood that a position will be available when their training is completed is understandably high.

We recently held town halls for folks interested in pursuing an academic career at U of T, to talk about the recruitment process. Each physician-in-chief (PIC) /chief gave a brief presentation outlining the strategic priorities of their hospital and potential recruitment opportunities in the next few years. Each PIC/chief talked about how recruitment at the hospital level has changed in recent years. Where once recruitment was almost as simple as a hand shake, it is now a much more rigorous and demanding process by which the PIC/chief must “justify” recruitment to hospital leadership, and negotiation for space and resources is challenging.

This shift has obviously stemmed from a substantial tightening of belts within the healthcare sector. Fewer resources, including space (hospital beds, ambulatory clinic space), procedural time, and funds for academic salary support, combined with increased pressure on our academic health sciences centres to ensure recruitment is aligned with hospital strategic priorities and areas of focus, are impediments to open recruitment. Our “fee for service” method of reimbursement may further disincentive recruitment as an increase in the number of faculty members may negatively impact personal income when the pie is fixed.

At the same time, we live in one of the most expensive cities in North America. As articulated to me recently by senior faculty member Dan Drucker, “Young recruits have families, expenses, housing worries/aspirations, mortgages, spouses with competing careers and needs, child care issues, not to mention competitive careers in scholarship that need to be transitioned seamlessly. There are external competitions, deadlines, and funding opportunities that are rigid in regard to application dates and insensitive to how slow or fast we move at U of T.” The requirement for a formal search process for all full-time faculty recruits may be seen in this light as making the process even lengthier, but done properly, this need not be the case. Formalizing the recruitment process helps address concerns regarding fairness and transparency and the need to balance the desire to provide opportunities for our own trainees with the strength that we get from the diversity that comes with recruiting faculty with different backgrounds and training. While I expect the recent experiences of our young faculty have varied, for some there is no question that the recruitment process has been incredibly stressful and perhaps even deflating. We can and must do better.

Before discussing potential approaches to address these issues, I want to dispel the misperception that ‘there are no jobs.’ Faculty renewal is integral to achieving our mandate. As an academic institution, it is critical that we continue to evolve – develop new skills and augment those we already have.

Since 2000, we have newly appointed 545 new full-time clinical faculty members at our fully-affiliated teaching hospitals (out of a total of 1010 new appointments) with an average of 32 new full-time appointments per year (range 16-48). Table 1. If anything, the number of new recruits each year has increased in the past 5-10 years.

Table 1: New Full-Time Clinical Faculty Appointments since 2000

Of these 545 new appointees, 210 (38.5%) were appointed as clinician-teachers, 23.7% and 22.9%, respectively,  as clinician-investigators and scientists, 6.2% as clinician-educators, 2.8% as clinicians in quality and innovation, and 1.2% as clinician-administrators. Figure 1

All this to say – there ARE jobs and we ARE recruiting, but…

Given how precious resources are within academic medicine, and the current pressures on our future academic leaders to find positions, it is time to take a close look at our recruitment, retention and retirement practices. With substantial input from our leaders, here are some suggestions for your consideration:   

Promote city-wide recruitment planning that incorporates a one to three year view, wherever possible

First, closer collaboration/planning for recruitment between the U of T training programs and the PICs/chief may be helpful to identify academic hopefuls and understand their career goals and potential ‘fit’ with the strategic plans, resources and clinical needs of the teaching hospitals as far in advance as possible. Often trainee career planning is left to the divisional program and departmental directors but, in the end, they are not the ones who seal the recruitment deal. Further, it is often left to the trainee to figure out who to talk to and when. This could be easily formalized to reduce the guess work. Second, where possible, PICs/chief should be encouraged to consider establishing search processes where multiple candidates would be identified, for staggered recruitment over a one to three year process. That way, a young physician would know that upon completion of their advanced training in a year, or two, they have a position to go to. Not a simple ask, but let’s keep talking. Finally, perhaps a simplified process for local searches needs to be considered.

Fulfilling expectations of the Academic Position Description

Given the pressures within the healthcare system and on academic medicine specifically, it is incumbent upon us to ensure that our faculty members are making a full contribution to the clinical and academic mission of their division and department in accordance with their academic position description (APD). This includes clinical work, such as on-call duties and coverage of inpatient and consult services as appropriate for the hospital and division, as well as teaching and scholarship. It is for this reason that we have established the Clinician Scientist Merit Review Process and enhanced the clarity regarding expectations of each of our APDs, available on our departmental website.

The PIC/chief or delegate is charged with the primary responsibility to assign hospital resources to support clinical work (e.g. endoscopy and dialysis time, reading of ECG, EEG, echo, PFT, sleep studies and EMG testing, etc.), teaching, research and administrative activities in accordance with the APD and to ensure the commitments of the division and department are met. Where an individual may no longer wish to, or be able to, meet the expectations of their APD, reallocation of hospital and University resources may be required to enable recruitment of new faculty to fulfill the obligations of the hospital or department. Thus, as part of the annual review, all faculty members, irrespective of career stage, should be asked about their three to five year career goals to assist the hospital and department with planning.

Late Career Transitions

As we know, late career transition to retirement can be extremely difficult. Currently, 12% of our full-time faculty members are aged 65 years or older, of which almost one-quarter are 70-74 years and 13% 75+ years. Many of these late career faculty members remain academically productive and contribute valuably to the academic mission. Still, the reality is that for many hospitals and divisions, recruitment of the next generation of academics relies heavily on others ‘making room’ for them. This situation may be time limited as the baby boomer bulge moves through, but right now it is a barrier to recruitment.

For some, there are financial barriers to retirement. Financial planning is the responsibility of the department member. Planning for retirement must begin early. To this end, the Department of Medicine will be implementing annual financial planning workshops. Many of the hospitals also provide such services. We strongly encourage all faculty members, from recruitment onwards, to take advantage of these opportunities.

But beyond finances, more often than not it is the faculty member’s desire to remain engaged in clinical medicine, teaching and research that makes retirement inconceivable. To this end, Dr. Liesly Lee has been chairing a ‘late career transition’ task force (please see his editorial in this edition of Medicine Matters). The goal of his group has been to develop a ‘toolkit’ for late career transition, which will incorporate formal mentorship and presentation of a variety of activities to allow continued engagement in the academic and clinical enterprise post ‘retirement,’ if desired. For example, we are exploring opportunities for senior clinician ‘consultancies’ in our academic family health teams, specific roles in the new CBD curriculum (who better to evaluate residents with respect to achievement of entrustable professional activities, EPAs?), departmental committee membership/leadership, and others. Further, we will be providing space in our new departmental location at the C. David Naylor Building beside the Medical Sciences Building on campus for our emeriti faculty to continue to interact with trainees, colleagues and peers. No one wants to push people out who have been enormous contributors over many, many years, but we do need to find opportunities for successful, respectful ‘transition’ of these faculty members to new roles to enable the faculty renewal that is so critical to a research-intensive university.

Summary

In summary, recruitment and retention of the best and the brightest is critical to the ongoing success of our department and the University as a whole. Successful recruitment of a current or future star in academic medicine is thrilling and breathes new life into our academic environment. We need to make some changes to our current processes, and perhaps thinking, to ensure that instead of ‘eating our young,’ we welcome them with open arms and support and nurture their careers. As always, let me know your thoughts.