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One-Track Mind

Steve Sisson is making his mark at Hopkins as a top teacher. Yet, unless the paper he's written about his curriculum is accepted for publication, he can't be promoted. He's now trying for the seventh time to make that happen.

By Mary Ann Ayd

Stephen Sisson admits he could be the poster child for tripping on the path to promotion. He isn't bitter. But neither is he an associate professor. Despite having come up with a Web-based curriculum for teaching outpatient internal medicine that's used by some 3,000 residents in 40 training programs across the country, the director of house staff practice and ambulatory medicine for the Department of Medicine has hit a brick wall trying to demonstrate that what he does has an impact. Six times the paper he's written (and revised and rewritten and revised and rewritten) has been turned down for publication. The last rejection came with one particularly frustrating comment: "These data seem old."

Yet without a peer-reviewed journal giving its stamp of approval to his work, Sisson can't take his teaching portfolio to the Associate Professor Promotions Committee. Is he an example of someone who should forget about a career in academic medicine at Hopkins? Or is he a pioneer?

How to determine the answer to that question is a hot topic on this medical campus. Since the School of Medicine began in the last days of the 19th century, it has used one set of standards to assess its faculty members. To be put up for promotion, they must publish in recognized journals, hold important research grants to support their laboratory work and receive sterling comments about their contributions to medicine in letters solicited from peers outside the institution. All of these criteria must demonstrate incontrovertibly that the faculty member in question is an innovator in his discipline. A national reputation is required to move up from assistant professor to associate professor, an internationional one to become a full professor. In the past, this widespread recognition could only be attained by publishing work that offered new insights into disease. Today, faculty members like Sisson have chosen to make their mark instead in the teaching arena.

The School of Medicine is hardly alone in wrangling with ways to evaluate faculty whose primary strengths lie not in research, but in teaching or patient care. But unlike Hopkins, nearly all U.S. medical schools have created distinct promotion tracks, often with distinguishing titles such as clinical professor and research professor, clinician/educator, etc. At these schools, faculty can focus on the core value that interests them most -- research, teaching or patient care -- and be promoted by contributing to their institution and their local medical scene. In fact, according to the Association of American Medical College's last survey of faculty personnel policies in 1999, only Rush Medical School in Chicago and Mayo Medical School joined Hopkins in sticking with a single-track promotion system.

The national shift by most academic medical centers toward multitrack medical faculties began in the 1960s when the dawn of Medicare and Medicaid prompted them to beef up their clinical enterprises. With the advent of managed care and its rigid payment systems some two decades later, these institutions found themselves facing economic disaster if they didn't see more patients. To bring in more dollars, faculty physicians simply had to take on heavier case loads. That left most of them with little time for research. To solve the promotion problem, medical schools developed new criteria for moving faculty up the ladder. They stopped expecting everyone to be researchers and began recognizing clinical excellence as another road to advancement.

Different tracks produce a two-class system. "The academic faculty look on the clinicians as not true academics, and the clinicians build up resentment about bringing in clinical income to support the academics."
Brooks Jackson

But the problem with that approach, says Brooks Jackson, current chairman of Hopkins' Professorial Promotions Committee, is that different tracks produce a two-class system. "The academic faculty look on the clinicians as not true academics, and the clinicians build up resentment about bringing in clinical income to support the academics. As soon as you start settling for a lower standard, faculty who only do clinical work, then it becomes, I could make more money in private practice. They leave -- and take patients with them.

"It's a slippery slope that will make this institution weaker," says Jackson, who is also director of the Department of Pathology. "I've been at five other places, and by far and away this is the best system. It generates mutual respect when you have people who share the same values."

When Stephen Sisson arrived at Hopkins in 1990 to begin his residency in general internal medicine, he envisioned a professional life dominated by research. The young man who'd wanted to be a physician since he was 8 had become so enamored of the investigative side of medicine that between his third and fourth years at Tufts medical school, he jumped at the chance to spend a year in the lab studying inflammatory cytokines. It never occurred to him that his experience at Hopkins would awaken a different passion. "Hopkins' clinical training is so strong" he says, "that my love for clinical work and education superseded my love for the lab."

By 1996, the year Sisson signed on as an assistant professor with General Internal Medicine, Hopkins was well on its way to expanding the division. Looking at the changing dynamics of health care, former Department of Medicine Chairman Jack Stobo recognized a need to increase its number of internists (in 1992 Hopkins had only three clinically active generalists; six years later, there were 17). In 1995, when John Flynn took over as clinical director of internal medicine, he increased inpatient admissions 161 percent in his first four months on the job.

Like the others who swelled the division's ranks, Sisson embraced the work. Yes, it meant devoting the bulk of his time to caring for patients and teaching -- today, he is the primary care provider for about 1,000 patients and supervises the training of 60 house staff -- but that, he says, is precisely what he was hired to do and it suits him to a T. Still, Sisson had read the Gold Book, the pamphlet that spells out Hopkins' criteria for faculty promotions. In deciding to demonstrate his scholarly activity by developing an Internet curriculum in his field for teaching residents, Sisson knew he was taking a gamble.

If Johns Hopkins has remained steadfast in its insistence on a single-track promotion system, it's not for want of debate. In 1988, the New England Journal of Medicine published a Hopkins study that compared promotion data for clinician-teachers and researchers. Results showed no significant differences between clinical and research faculty in terms of their probability of promotion or age at time of promotion. Those who were promoted, however, had about twice as many articles published in peer-reviewed journals. The authors, including Hopkins faculty members Leslie Plotnick and Brent Petty, recommended improved counseling for faculty members and more extensive discussion of promotion criteria.

In the early 1990s, Paul McHugh plunged into the discussion, drawing on his years as head of both the associate and professorial promotions committees here. Setting out to explain what he says the Gold Book's "exalted language" doesn't really explain-how promotion committees assess scholarly achievement when one day the candidate may be a biochemist, the next, a gastrointestinal surgeon -- McHugh penned a monograph that began as a lengthy internal memo and evolved into a widely read article in Academic Medicine. The crucial focus must be on a nominee's ability to produce knowledge, disseminate knowledge and apply knowledge, the outspoken former psychiatry chairman wrote. "If you want to advance academically you have to have more than testimonials from patients and students. Otherwise, it's a popularity contest -- whether people like, or don't like, the cut of your jib."

"You can rise to professor and have a life; you just make choices."
Julia Haller

By 1996, when the first dean and CEO of Johns Hopkins Medicine, Edward Miller, took office, Hopkins' single-track promotion system was clearly an issue within faculty ranks. Miller tapped Edward Benz, who was then the chairman of Medicine, to head a committee charged with revisiting whether there should be more than one promotion track here. Should the School of Medicine set up a parallel road to advancement, Miller wanted to know? Should it allow physicians consumed by clinical work to be assessed on criteria other than their publishing record?

In the end, the Benz committee reiterated Hopkins' traditional stance that separate criteria would create second-class citizens. But it also called for formally expanding what counted as achievement. Such activities as developing a new curriculum for teaching medical students or residents or creating an important medical procedure should also carry weight.

Meanwhile, the Professorial Promotions Committee itself, looking into problem of shrinking time for scholarly work, issued its own report. Among its conclusions: Hopkins couldn't lower the bar for promotion to full professor without cheapening its core values. But the criteria used to assess scholarly impact and recognition no longer could rest solely on whether a faculty member held prestigious research grants or had been published in Science.

With all of these recommendations on their lap and faculty physicians feeling increasingly pressured to see more patients, in 1999, institutional leaders finally agreed to entertain a proposal that differentiated between an academic appointment in the School of Medicine and a professional appointment in the Hospital. Word went out that for the first time in its history Johns Hopkins was considering hiring two kinds of physicians -- one group that would focus on clinical work, another that would adhere to the traditional criteria for promotion. This time, it was the faculty itself who backed off.

"I was surprised by the push-back from the faculty," Miller says. "They made two things very clear. First, they don't want two classes of citizens. Hopkins has just one faculty -- with a maniacal interest in excellence. Second, just taking good care of patients and just teaching medical students and house officers isn't enough. Our job is to train academics. They have to document what they do; they need to make that extra effort that goes into publishing."

Whatever the inner drive that propels a faculty member toward the academic summit, no one argues that it's easy to get there. One thing is clear, though. In Hopkins' decentralized organizational structure, the responsibility for seeing to it that junior faculty don't flounder on their way up rests on the shoulders of division and department heads.

"It's the chairman's job to recruit and put together resources that allow people to prosper," says Pediatrics Chairman and Professorial Promotions Committee member George Dover. "And here, prospering means not practicing medicine, but changing medicine -- that's the fundamental charge of this institution. It's not a downhill path where you just start walking and gravity will take you there. You need brains, muscle and probably a bit of luck."

"Mort Goldberg [who just stepped down as head of Hopkins' Wilmer Eye Institute] has said, 'When you come here, you're given a hunting license.' You have to take the initiative, find your own niche, use your own ingenuity. When people say you can't do it, that's not accurate. It flies in the face of the accomplishments. But you do need more than your own energy -- you need colleagues and mentors."

For Pamela Lipsett, who this year became Hopkins' first-ever female professor of surgery, where to find those mentors wasn't obvious at first. No one else at Hopkins was then studying the field that intrigued her -- surgical infection. Even so, she found people both in surgery and other departments willing to take an interest in her career. One was biochemistry whiz James Hildreth, who "didn't know about surgery but had tools that could help me in my area."

"Steve is an innovative teacher, and he has a product that proves that. The problem is, how do you judge an outstanding teacher who gets great reviews, but has no publications?"
Michael Klag

Equally important, says Lipsett, was the guidance she received from John Cameron, then director of surgery. "He'd meet with us twice a year, and he was clear about what was necessary at each step, what societies to join, how to make a local, regional, national, international reputation. Although he very much left it to me to accomplish, he'd say, This is what you need to do next. My impression is that he had some idea of each faculty member's progression and had a plan for everyone.

"I don't think any other institution save Harvard has the same expectations," Lipsett says. "Whether you're a medical student, an instructor or a professor at Hopkins, you're already special. It's not a matter of tradition, or 'It was hard for me so it should be hard for you'. Our standards shouldn't be lowered."

Julia Haller agrees. Two years ago, at 46, Haller was promoted to professor of ophthalmology on the strength of what she modestly calls "more yeomanlike bludgeoning than a very focused, single discovery." Today, the Katharine Graham Professor of Ophthalmology maintains that the most brilliant Ph.D. on the Homewood campus has to feel satisfied that a full professor at the School of Medicine meets comparable standards to someone in Arts & Sciences. "I take care of lots of patients, I teach residents and fellows, I write papers," says the vitreoretinal surgeon. "You can rise to professor and have a life; you just make choices."

Finding time outside the operating room can be tough, but Haller, a mother of five, also is an expert in retinal diseases. Her credentials were so strong, says Biophysics and Biophysical Chemistry Director Jeremy Berg, who chaired the promotions committee when Haller was under consideration, that the outside letters documenting her qualifications could be summed up in one word: Duh!

"I've seen so many good examples of people juggling a lot of balls," Haller says. "The most efficient way to maintain a practice and do clinical research is to have normal patient care rolled into clinical studies. That way, when you have patients with diabetes, for example, you can do their regular exam as part of the study. We make an effort to bring junior faculty along: we're good at giving up-and-comers the chance to be principal investigators."

Haller doesn't favor separate promotional tracks. "If you told my friends from college that I was a clinical professor, they wouldn't know the difference," she says. "But people in the know would -- and they're the ones you really care about, aren't they? The only way to reward here is to promote, so we have to think about what we want to reward. There's much more acceptance now of non-traditional areas of research in which outstanding clinicians who are not bench researchers can contribute. I do think we sometimes miss the boat, though: Someone who could be an outstanding teacher may spend his or her energy writing papers instead, because that's where you get rewarded."

What rankles Steve Sisson about trying to reach the next rung of Hopkins' promotion ladder isn't exactly time. The School of Medicine long ago abandoned the unforgiving "up-or-out" clock that used to hang over faculty members' heads in favor of contract extensions that allow department directors more leeway in keeping promising faculty on board. Furthermore, the Web-based curriculum Sisson was spearheading struck his superiors in the Department of Medicine as so full of potential that they freed him from some of his heavy clinical duties to give him time to work on it.

And, it seems, they backed a good horse: Sisson has not only garnered his department's teaching award for excellence and was Hopkins' 2002 nominee for the Association of American Medical College's annual Humanism in Medicine Award, but his Johns Hopkins Internal Medicine Internet-based Program for Ambulatory Care Education has been picked up by the likes of Duke, Tufts and Mayo.

"Steve is an innovative teacher, and he has a product that proves that," says Vice Dean for Clinical Investigation Michael Klag, who was interim chairman of Medicine when Sisson was recommended for promotion to associate professor. "That's been judged by his peers at other institutions. There's not much gray in my mind about him. The problem is, how do you judge an outstanding teacher who gets great reviews, but has no publications? Every organization reflects its own origins and the personality of its leaders. Ours was set up as a research university. Can you be promoted for teaching, without publications? I doubt it. Not here. Sisson is smart, he works hard, he's come up with innovative stuff. The department's come back to him and said, Just publish this."

And therein lies Sisson's conundrum. Options for publishing reports on educational interventions are few, he says. "But the fact that 40 of my peers, who are residency training program directors at other top teaching hospitals, have reviewed my curriculum and chosen it for use in their educational program isn't even considered by the committee in my department that recommends assistant professors for promotion."

"Hopkins is one of the top 10 places in the world for medicine. Promotions here should be predicated on extraordinary work."
Dean Edward Miller

A 1999 New England Journal of Medicine article, "Mission Critical: Integrating Clinician-Educators into Academic Medical Centers," postulated that although the mission of AMCs is research, teaching and patient care, reward and promotion systems favor those who do research -- whether it's clinical or basic science.

What's clear is that competing successfully for grants and getting published in top-tier journals are accomplishments that give promotions committees something objective to sink their teeth into. "Still," says David Hellmann, director of the Department of Medicine at Johns Hopkins Bayview Medical Center, "I don't accept that you can't measure teaching excellence and clinical excellence. And if Hopkins

believes the three parts of its mission -- research teaching and patient care -- are equal, and they are always drawn as an equilateral triangle, then we should reward each of them equally."

And, says Sisson, let's do it without creating a caste system. "Whenever I hear two-track, my heart always sinks a bit. Trying to fix the problem by giving clinician-educators a different name doesn't answer the question."

Miller, the dean, however, remains firm. "The only acceptable way so far to evaluate a faculty member's achievements is through publications," he says. "I have no doubt that good teaching is important. But there has to be a way to document that, too. We do have to make sure the criteria are broad enough that superb clinician-educators can advance. But in the end, Hopkins is one of the top 10 places in the world for medicine. Promotions here should be predicated on extraordinary work."