Abstract
Mentoring, assessing, and rewarding faculty who have clinical service responsibilities with promotion and tenure can be challenging in many respects. Clinical service responsibilities can limit the time that faculty have available to participate in scholarly activities, especially if the scholarship required for promotion is restricted to traditional research efforts where an individual faculty member is assessed in terms of the number of scientific publications in high-tiered journals with senior authorship and the amount of extramural funding garnered. Even if other forms of scholarship are recognized, metrics used to evaluate research efforts are often inappropriately applied to other scholarly activities. This challenge is not unique to veterinary medicine. This literature review reveals information regarding barriers and recommended solutions from other healthcare and service professions as recognizing scholarly engagement in academic veterinary medicine is just beginning. Opportunities and examples of how faculty can derive scholarship from their clinical service activities are provided. In addition, an approach for mentoring faculty in the prospective planning and documenting of scholarly engagement efforts is suggested. Lastly, challenges and guidance for assessing such scholarship in academic veterinary medicine are recommended as one step toward encouraging colleges of veterinary medicine to develop methods to assess scholarly engagement within their promotion and tenure processes. A change in approach to the promotion and tenure process can result in more faculty being rewarded for their clinical, diagnostic, and scholarly excellence, which positively impacts patient care, career fulfillment, institutional reputation, the veterinary profession, and society as a whole.
Faculty at veterinary educational institutions are challenged with prudently allocating limited time and resources to meet career and personal responsibilities without sacrificing wellness.1 Tenure-track faculty working in clinical or diagnostic laboratory settings (hospital, field services, or diagnostic services) face the added challenge of making time to engage in scholarly efforts, often while navigating conflicting messages of what is expected to meet promotion and tenure requirements.2–4 For example, good citizenship in terms of committee service is important and expected of all faculty; yet, promotion and tenure is primarily based on scholarly activities.
Underrepresented tenure-track faculty with clinical or diagnostic laboratory responsibilities might have even fewer opportunities to find time for scholarship because they are disproportionally asked to participate in service and mentorship activities as a representative of their gender, race, sexual orientation, or ethnicity compared to majority faculty.5–10 In addition to increased service and mentoring responsibilities, inflexible research expectations and marginalization of research have been identified as obstacles to promotion and tenure for underrepresented faculty.9,10 Moreover, regardless of clinical responsibilities, underrepresented faculty can face additional challenges. Twenty-two percent of underrepresented faculty as compared to 6% of majority faculty from 26 US human medical schools reported experiencing racial/ethnic discrimination.11 Microaggressions and inequitable expectations during the promotions and tenure process can impact wellness through the manifestation of psychological and physiologic stress responses10,12; and compel faculty to leave academia.10 Recruitment and retention of underrepresented faculty to academia should be a priority considering a diverse faculty is important for students to develop the cultural competencies essential for successful practice in our increasingly diverse society.11 Unfortunately, in 2016, only 16.5% of tenured or tenure-track faculty, and 5% of non-tenure clinical track faculty in US schools of veterinary medicine were racially and ethnically underrepresented in veterinary medicine.13
Recruitment and retention of faculty with clinical service responsibilities is essential for colleges and schools of veterinary medicine to train veterinary students and specialists; attract an adequate caseload; and, advance the profession through generation of new knowledge.14–17 Respondents to a 2003 survey of recently hired clinical specialists at colleges of veterinary medicine reported collegiality and workplace climate as the most important factor, and ranked administrative support seventh, of eight categories considered when deciding to take an academic position.17 Included in the category of administrative support was the clarity of the promotions and tenure process.17 The distribution of time for scholarship fell in the category of institutional support which was ranked third.17 On the retention side, respondents to a 2004 survey of American College of Veterinary Surgeons diplomates reported not wanting to do research, lack of administrative support, and difficulties in meeting expectations for promotion and tenure, among the reasons for moving from positions in academia to private practice.14 Not much changed when, 11 years later, respondents to a survey of board certified veterinary specialists reported lack of recognition for clinical service, lack of interest in research, and “too great of an expectation for research” among reasons for leaving academia.15 One option for attracting and retaining clinical specialists to academia was development of non-tenure, clinician-educator faculty positions. These clinical track positions offered specialists the opportunity to practice in an academic environment without research expectations; however, scholarship was still expected for promotion.18
Barriers to finding opportunities to generate scholarship outside of traditional research have been reported in other healthcare professions such as human medicine, nursing, dentistry, and pharmacy.4,19 In human medicine, like veterinary medicine, faculty with hospital appointments have multiple roles, including patient care, service to community, teaching, and research.4 The role of academic physicians has changed over time from researchers with secondary teaching and patient care roles, to clinicians spending most of their time in patient care roles to generate income for their institution in the face of declines in state subsidies and grant funding.4,20 However, despite changes in roles, the criteria for promotion and tenure remained research-focused.20 The result is academic physicians with conflicting expectations in their roles as researchers/educators producing journal publications and as clinicians whose major responsibilities are teaching and patient care.4
We cannot afford to send the message that if you want tenure, “We need more than what you have and then we need more than that.”21 The ramifications could lead to wellness issues22,23; contribute to a hidden curriculum24 that might dissuade students and residents from careers in academic veterinary medicine; or compel specialists to leave academia. We must find a sustainable means of guiding and supporting faculty who have extensive patient care or diagnostic laboratory service obligations through the promotion and tenure process in such a way that their quality of life and passion for veterinary medical education is maintained.
Service is a valued and important means for faculty to impact and bring visibility and recognition to their units and their institutions. Through internal service, faculty can influence academic oversight (curriculum review, admissions committee, academic standards committee); institutional governance (strategic planning, search committees, diversity action committee); and students (advising, mentoring, resident/graduate student committees).6 External service through professional associations, governmental affairs, clinical service, laboratory service, locums, or extension is also encouraged.6,25 External activities in particular can help faculty stay current on advances and challenges in their discipline which can extend to informing relevant and responsive curricula and research.25 Despite the expectation that faculty participate in a multitude of service activities, and the positive impact of such activities, service responsibilities have not traditionally been considered a form of scholarship.26 As this article is focused on promotion of tenure-track faculty working in clinical settings, we will concentrate on how faculty in patient care roles can derive scholarship from clinical service activities associated with their disciplinary specialty. These same principles can be applied to faculty in diagnostic laboratory settings or non-tenure track clinical faculty.
Boyer26 recognized the rigorous demands of professional service activities that result from application of discipline-based expertise to serve the larger community. Distinguishing these activities from social or civic service, he called this the “scholarship of application.”26 Boyer26 realized that intellectual advances in areas such as medical diagnosis, protocols, and policy can result directly from the application of knowledge. In 1996, Boyer27 coined the term, “scholarship of engagement,” to describe partnerships among academia and communities where university resources are used to address community and societal needs. Duke and Moss28 recognized that in the field of nursing, partnerships among communities and academia provided access to practicing clinicians, patients from the community, industry, and clinical data, all of which are essential for nurses to generate and transfer new knowledge. The same could be said for both human and veterinary medicine. Sandman29 summarized two core principles of scholarly engagement, as follows: (1) Scholarly engagement involves mutually beneficial partnerships differentiating it from service or outreach which is unidirectional; and (2) Scholarly engagement integrates learning, discovery, and service. As a result of these principles, engaged scholarship through clinical practice has the potential to lead to new and immediately relevant knowledge.30
Confounding the conversation is that clinical excellence is often perceived as equivalent to clinical scholarship. In human medicine, learned, passionate academic physicians with good interpersonal and communication skills who were skillful diagnosticians were considered excellent.31,32 These faculty are often caring, dedicated professionals who enjoy a strong reputation and bring in considerable hospital revenue.31,33 Wright et al.32 included achieving mastery in navigating the health care system, approaching practice in a scholarly manner, collaborating with others to advance research, and modeling clinical excellence to trainees, to their definition of clinical excellence. Such excellence should be rewarded, but is not scholarly in and of itself.33 Comparatively, Grigsby and Thorndyke33 identified attributes of clinical scholarship in human academic medicine. Clinical scholarship uses a systematic, scientific, interdisciplinary, team approach that generates valuable knowledge through the practice of academic medicine. The knowledge is used to improve the health care of individuals and communities. The resultant knowledge is communicated through manuscripts, presentations, consultation, or leadership positions. Documented evidence of adoption by others is of importance.
In the author’s opinion, two overarching issues are the main barriers to deriving scholarship from clinical service: the lack of time available for faculty to devote to scholarly endeavors; and, the subjectivity of the promotion and tenure process itself. The guidelines for promotion and tenure provided by institutions are open to interpretation by the users. Faculty attempt to reconcile their job responsibilities with expectations for promotion and tenure. During the decision-making process, guidelines can have mixed interpretations depending on the composition of the committees reviewing and voting on the documents in any given year. Moreover, universities establish promotion and tenure guidelines to which colleges and schools of veterinary medicine must adhere. Forms of scholarship conducive to promotion of faculty with clinical service responsibilities might be considerably more difficult to get recognized, or advocate for, at institutions without health professional schools, or as the dossier moves within and beyond the veterinary college, to committees where scholarly clinical contributions might not be understood or valued.18
At some institutions, the climate openly or subtly discourages forms of scholarship other than research.4 Failure to be promoted can be interpreted by faculty as a bias against race or ethnicity34 or a bias against those with clinical appointments.4,19 These perceptions are not unfounded. Research has shown that after adjusting for academic productivity,34–36 and time on clinical service,34 White faculty were more likely to be promoted to senior ranks in human medical schools, despite increasing numbers of minority faculty.
In addition, research has traditionally been the pathway toward promotion and tenure,3,28,30,33,37,38 and other forms of scholarship are not always recognized.4 A survey on the promotions process at Johns Hopkins School of Medicine found that faculty in clinical teaching roles (70%–90% of time spent in patient care and the remainder in teaching) were less likely to be at a higher rank than faculty in basic or clinical research roles (more than 50% of time spent in research).39 Equivalent data from veterinary institutions regarding time to promotion of faculty with patient care responsibilities compared to faculty in research roles were not found by the author.
After analyzing 142 US and Canadian human medical school websites, Goldstein and Bearman40 reported that no human medical school listed scholarly engagement as a primary criterion for promotion and tenure; but 12 schools mentioned it as being considered during the process, sending a message that faculty should spend their time in other areas of scholarship. Similar information for academic veterinary medicine was limited in scope. Thirteen of the 30 US schools/colleges of veterinary medicine had public facing promotion and tenure guideline documents available online.41–53 A review of the available documents found that only two colleges explicitly cited Boyer’s scholarship of application26 as a means for promotion and tenure.50,52 Although not explicit, many recognized scholarship associated with clinical service activities.41,44,47,48,51,53 Others stated that scholarship can be associated with all areas, but only listed scholarship in terms of research or teaching42,46 or explicitly cited expectations for scholarship in research or teaching.43,45,49 This available data suggests that scholarship associated with clinical service, in theory, is not a barrier at some institutions. However, since less than half of these institutions publicly provided documents, and since public documents might not offer complete or detailed information, this review has significant limitations and might not be representative of the state of academic veterinary medicine.
In practice, a lack of awareness of forms of scholarship by faculty outside of research or role models performing scholarly engagement or teaching can be barriers.4,37 Even if aware, many faculty members often do not have an understanding of the early career planning and information needed to derive and document scholarship from clinical activities,4,37 or faculty do not have the desire or understanding of how to publish in this area. These factors, coupled with unclear expectations and a lack of examples of alternative forms of scholarship, can all hinder promotion of faculty with clinical responsibilities.4,20,37 While we cannot easily overcome these challenges, we can do our best to position our faculty for success in scholarly endeavors.
Calleson et al.54 recommend three categories of products that can stem from scholarly engagement: (1) peer-reviewed publications, which can describe innovations in practice, service-learning programs, methods/lessons learned for replicating successful programs in other communities, or community-based research; (2) applied products, which result in immediate application of disciplinary knowledge to practice such as developing innovative programs, new local state or federal policies, or training/technical assistance guides; and (3) products disseminated to the community, such as individual presentations or community forums, news articles, or websites.
While providing excellent clinical service in and of itself does not constitute scholarship,3 we do not need to recommend that faculty embark on entirely new traditional discovery efforts to generate scholarly products. Instead, we can help faculty derive scholarship from the daily clinical activities for which they are already passionate. For example, delivering clinical care to an underserved community would not be considered a scholarly endeavor. However, this practice could be considered scholarly if innovative means of delivering healthcare to the community including procedures for others to replicate the program in their communities were published,54 or the program and outcomes were presented to local, regional and national community leaders or policy makers.55 Garnering competitive external funding for the program is another indicator of peer recognition and scholarship.55 Other suggestions for how scholarship can be derived from clinical service are as follows:
Innovative or improved diagnostic approaches, treatment modalities, biomedical devices, surgical techniques, or translational medicine techniques developed as a result of patient care activities can be made scholarly through assessment and documentation of clear impact on the patients or practice of veterinary medicine (i.e., improved survival rates, improved health outcomes, decreased time to diagnosis, more accurate diagnosis, replacement of previous gold standard) and presented (invited presentations), and published (peer-reviewed clinical or laboratory research articles, case reports, retrospective studies, meta-analyses, textbooks, reference books, book chapters).3,33,37,55 This area likely provides the most recognized opportunity for faculty in patient care roles in veterinary medicine to develop the scholarship necessary for promotion. Focusing scholarship in a specific area for which the faculty member wishes to establish national or international recognition can strengthen this approach.
Development of clinical guidelines, protocols, or health and wellness programs that improve quality of patient care, safety, clinical outcomes,33,56 client compliance, client communication, or client satisfaction3 can be made scholarly through presentations and publications, such that they can be used by others and translated to policy or best practices. Publishing strategies to control nosocomial infections57 or infectious disease in livestock populations,58 are examples from veterinary medicine.
Developing, assessing, and publishing best practices that can be used as community or professional resources such as “how-to” guides for establishing community programs; securing and sustaining community partnerships; approaching complex medical problems using interdisciplinary teams; or assessing program outcomes,28,33,55 are examples of scholarship. Turning a news article59 into a peer-reviewed manuscript detailing the approach that the Cummings School of Veterinary Medicine at Tufts University took as they partnered with Worcester Technical High School to train future veterinary professionals and provide veterinary care to an underserved community would be an example of scholarship that could serve as a model for other veterinary institutions.
Continuing education presentations or workshops can have scholarly impact by using them as the basis for clinical review articles, evidence-based reports, literature reviews, meta-analyses, or commentaries.60 The resultant peer-reviewed manuscripts can reach a broader audience and serve as a scholarly product.60 Such presentations can be geared toward the general public and used as the basis for a newspaper column or radio show on a medical topic, where the faculty member is using their expertise as well as novel ways to distribute medical advances.2 Impact measures can include peer review by other medical experts and numbers of readers or listeners.2
Developing a service that was not previously offered can be considered scholarship through presentations and publications of the approach, impact, and lessons learned, that would allow replication by others. Packer et al.61 provide an example from veterinary medicine in which establishment of a neurology service at Purdue University College of Veterinary Medicine is described. Using patient care income to fund new clinical specialties that are then used to produce scholarship has also been suggested as a form of scholarly engagement.20 Lewbart et al.62 provide another example in which a wild-turtle clinic was founded at North Carolina State University College of Veterinary Medicine. The Turtle Rescue Team engages students, faculty, the public, and local wildlife rehabilitators.62 New services can undoubtedly enhance teaching by attracting hospital referrals and subsequently increasing and diversifying caseload.
Service-learning programs involving community partners are an excellent example of scholarly engagement. Degernes and Nettifee Osborne63 describe an innovative model for teaching veterinary students raptor medicine through a partnership with a raptor rehabilitation center. Elective courses and laboratories were developed and impact on student learning was assessed. Spay-neuter programs are another example from veterinary medicine. Such educational experiences are mutually beneficial because they provide learning opportunities for students while fostering partnerships that meet community and societal needs. Documenting, publishing, and presenting development of the program itself, or impact on students (increased surgical experience, improvement in surgical skills and confidence, improved understanding of shelter medicine); the institution (increased resources, positive publicity); the community (decreased shelter costs, increased adoption rate); and, society (decreased stray population, improved public health) can all be the basis for scholarship.64,65
Faculty with clinical appointments can build strong interdisciplinary research collaborations by identifying and disseminating solutions to clinical problems.56 More traditional scholarship can involve taking a leadership role in clinical studies to assess the effectiveness of a drug, other intervention, diagnostic tool, treatment, or preventive strategy.3 Prospective randomized clinical trials are well-positioned to have an expanded role in veterinary medicine66 providing clinical faculty with an opportunity to generate scholarship. For example, veterinary clinical trials in oncology using spontaneously occurring cancers in pets can be used to advance both human and veterinary oncology.67 Participants in a translational cancer research workshop noted that although there was limited capacity for veterinary clinical trials in the US, they were underutilized in cancer research.68(p.11,51) In addition to publishing clinical trial results, scholarship can be derived from manuscripts that inform veterinary medical clinical trial design, limitations, ethical concerns, and interpretation of results. Examples of these complementary forms of scholarship in veterinary medicine include providing guidance for conducting and interpreting noninferiority clinical trials using veterinary patients69; reporting factors that impact client participation in veterinary clinical trials70; and, providing information for practicing veterinarians to interpret the relevance of veterinary clinical trial results.71
Although not the focus of this article, one can also add activities that exemplify the scholarship of learning to this list. Scholarly products can take the form of publications or presentations about strategies for teaching students, or engaging students in learning a difficult procedure or concept, and then assessing their learning.2
A prospective approach to planning and documenting scholarly engagement is much easier than a retrospective approach37 considering scholarly engagement activities typically take years before academic or community impacts can be measured.3,54
Brodell37 recommends that the faculty member start by developing a mission and goals statement to ensure that the activity is consistent with the mission and goals of the university. The activity should also be consistent with the expectations of the faculty member’s appointment and the promotion and tenure requirements of the institution.
As associate dean for engagement at the Purdue University College of Veterinary Medicine, I often meet with faculty to discuss their interest in, and documentation, of scholarly engagement activities. We discuss how program/project ideas fulfill the core principles of scholarly engagement. Namely, the activity addresses a need identified by the community72 or profession; involves a mutually beneficial collaboration among community and university partners; and includes scholarship. We also clarify what scholarly engagement is not. For example, documenting numbers of presentations, time on clinics, or numbers of cases seen, without documenting associated impact is not considered scholarship. As well, community involvement unrelated to discipline-based expertise is encouraged but not considered part of scholarly engagement efforts.
We look for projects that faculty are passionate about that also create synergies among their teaching, clinic, and discovery expectations.72 Once we find such a project that satisfies the core principles of engagement, we discuss a framework for the activity. The project should be innovative and have clear objectives. The project methods should be sufficiently documented such that it can be replicated and serve as a foundation for future projects by that faculty member or others. The outcome of the activity should be generation of new knowledge that changes behavior or practice resulting in measurable positive impact to the community, the profession, or the university. Ideally, since we are at an educational institution, the project would involve students. Metrics specific to the project are identified that will document impact, excellence, and peer recognition. A logic model is produced that includes for each objective: program elements, outcomes (products or deliverables stemming from each element), and measures of the impact of each outcome.
As a summary of the discussion, a compelling description of the project and how the activity directly or indirectly impacts participants, students, and brings value to the community or profession is drafted. A crucial piece of this initial draft is for the faculty member to describe the state of events before the project was initiated so that a baseline for determining impact can be established. This draft can then be the foundation for the final contribution to the faculty member’s promotion document. The draft can be discussed and revised at least annually through the lifespan of the project.
Even when the scholarship of engagement is recognized at institutions, benchmarks to evaluate research performance are typically inappropriately applied during assessment of faculty documents.19,20 A process for acknowledging the scholarship of engagement must be developed that will satisfy institutional research requirements or be rewarded at the same level as traditional research.28 Otherwise, faculty will either not spend their limited time on scholarly activities that could immediately contribute to the public good or they will remain unrewarded for finding time on top of their discovery efforts to participate in such activities.28,55
Rewarding faculty for engaged scholarship should not imply that standards for excellence will be reduced. Glassick et al.73 reviewed guidelines from universities, granting agencies, and scholarly journals and proposed six overarching standards for assessing any form of scholarship. First, the faculty member must have clear, achievable objectives that address important questions. Second, the faculty member must demonstrate adequate preparation. The faculty member should have an understanding of the current literature in the field, and the ability to combine the skills and resources needed to achieve the objectives. Third, the faculty member must use appropriate and effective methodology and be willing to modify the approach if necessary. Fourth, the results should significantly contribute to solving the problem, either by adding to the field, serving as a model for others, or by identifying further areas of inquiry. Fifth, the results should be effectively communicated and disseminated to appropriate audiences. Last, the faculty member should perform critical and constructive self and external reviews of their work to foster continuous improvement.
The following questions are suggested to guide the evaluation process when assessing scholarly engagement:
Does the activity address a community, societal, or professional need?74
Does the faculty member use discipline-related expertise?54
Does the activity have clear objectives?54
Is the activity innovative?54
Are the clinician’s specific and scholarly contributions documented?55
Are the methods documented sufficiently such that the activity can be replicated by others?
Is there documented and measurable impact (i.e., changes in policy28,54, improved health outcomes28,54; are there increased community resources,28,54 increased student understanding of community or professional needs,28 or impacts on student knowledge, career choice, attitudes, skills54)?
Is there peer review, and review by the recipient of the intervention, if applicable?3
Are there indicators of peer recognition (i.e., competitive funding, other resources brought to the university or community, invited presentations, publications in peer-reviewed journals)?54
Are there indicators of excellence (i.e., awards, honors, media recognition, economic impact, policy changes, patents)?
Academic leadership is encouraged to foster scholarly engagement efforts by providing guidelines for assessment in terms of scholarship, impact, and excellence to all faculty, including administrators and senior faculty serving on promotion and tenure committees. There should be general agreement as to the weighted value of various activities with clear delineations of what is considered a job expectation and what is considered scholarship as is found in Auburn University College of Veterinary Medicine’s guidelines.41 In the absence of such guidance, decision makers will likely default to traditional research benchmarks.
Institutions can benefit from supporting scholarly engagement activities. Hospitals can improve effectiveness and efficiency of service3; and increase retention of diverse faculty.2 At the local level, engaging communities can bring about a greater appreciation of the public for academic medicine2; thereby, improving political and financial support.3 The One Health initiative provides a multitude of opportunities to highlight the role of veterinarians in human, animal, and environmental health while serving disadvantaged populations.75
Publishing clear guidelines for promotion and tenure or for assessing scholarly engagement are necessary but likely the easiest first steps for change. Changing attitudes to encourage institutional climates that foster and reward scholarship in clinical settings will take work. We must send a clear message that scholarly engagement is important and valued. Administrators and senior faculty will need to take leadership roles in promoting, supporting, and rewarding such scholarship.3,30,55 To champion scholarly engagement, administrators and senior faculty must mentor other faculty; provide timely, detailed, and actionable feedback to faculty on their progress toward tenure; protect faculty time for scholarship4; provide resources to faculty such as writing workshops focused on preparing engagement publications; develop examples of documenting scholarship that can serve as models for faculty55; assist in developing promotion and tenure documents; serve as reviewers of scholarly engagement activities; and support promotion of faculty engaging in high quality, impactful scholarly engagement.3
Faculty will also need to choose to prioritize time to actively participate in and role model scholarly endeavors.30 Lastly, future faculty members will need to develop the tools for and expectation of engaging in such scholarly activities.30 Participation in scholarly activities during residency programs can seed an interest in pursuing careers in academic medicine and participating in scholarly activities after the residency.37,76
In summary, there are numerous ways that faculty can generate scholarship from clinical service activities that leadership at veterinary academic institutions can recognize, support, and model. The author recommends that leadership facilitate the success of faculty through mentorship programs that help faculty develop a prospective approach to planning and documenting such scholarship. Just as important, the author recommends that leadership develop and embrace methods to assess scholarly engagement within the promotion and tenure process. By not changing our approach to promotion and tenure of faculty with clinical service responsibilities, we risk deterring scholarly activities that contribute to the public good, sustain our faculty’s passion for veterinary medicine, and advance the veterinary profession. “In the end, research is most valued”77 is no longer an acceptable stance.
Acknowledgments
The author thanks Dr. Willie Reed, Dr. Steve Adams, and the external reviewers for their critical review of this article and their constructive feedback for improvement.
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