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    Is it time for term limits in academic medicine?

    Reshma Jagsi, MD, DPhil, spoke with AAMCNews about how term limits, particularly at the department chair level, are needed to diversify leadership in academic medicine.

    Reshma Jagsi, MD, DPhil Photo courtesy of Reshma Jagsi, MD, DPhil

    When Reshma Jagsi, MD, DPhil, attended Harvard Medical School in the 1990s, she wasn’t bothered by the fact that most of the department chairs and the dean were male. After all, Title IX had passed just 25 years prior, ushering in a vast expansion in the number of women attending medical school, from just under 10% in 1972 to almost 50% by the late 1990s.

    “It didn’t appear to my generation that there was anything to be particularly concerned about, because we knew that the people in leadership positions when we were in medical school were being drawn from a pool that mostly went to medical school in the 1970s or earlier, when medical students were largely male,” says Jagsi, now the Newman family professor and deputy chair in the Department of Radiation Oncology and director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan Medical School. “A lot of people thought this would just work itself out with the simple passage of time.”

    Fast forward to Jagsi’s recent 20-year medical school reunion. “My class was over half female and had some incredible rock stars,” Jagsi says. “There was no reason to believe that the men would outperform the women but … even in this highly accomplished, highly promising Harvard Medical School class, there were relatively few women who had reached leadership positions.”

    The numbers bear out her observations: While women have made up more than 40% of the medical student body for the last 25 years, they represent less than 20% of department chairs and deans.

    That’s just one reason why Jagsi is calling for term limits in academic medicine. In a recent Perspective piece for the New England Journal of Medicine, “Unplugging the Pipeline – A Call for Term Limits in Academic Medicine,” Jagsi and her co-authors laid out their case, noting that men occupy 84% of permanent department chairs, with some terms lasting as long as 43 years.

    “We believe that enacting term limits is an important and underused mechanism for increasing diversity, equity and inclusion within academic medicine,” they wrote, noting that the NIH recently implemented 12-year term limits for its tenured intramural laboratory and branch chiefs. “The NIH has recognized that lack of equal opportunity goes hand in hand with scientific stagnation. We believe it’s medicine’s turn to do the same.”

    Jagsi recently sat down with AAMCNews to talk about term limits, as well as the response she’s gotten since her Perspective was published.

    Why term limits, and why now?

    Certainly, there are multiple deep and complex barriers that are impeding achievement among women, including not only overt discrimination and sexual harassment but also gendered expectations and unconscious biases that can lead to differential assessments of merit between men and women. But another potential barrier is that the opportunities for advancement at the senior level are so few in academic medicine. For many years, the position of department chair has been such that once someone reaches that position, they may hold it for the remainder of their career. It can even seem an indignity if one is asked to step down. If someone is asked to step down, unless it’s for a higher position such as a dean position, at many institutions, people might furrow their brows and say, “Hm. I guess that person didn’t do very well in that leadership position.” But we know from the literature on organizational management and behavior that having some degree of diversity in the perspective of our leaders is valuable to our organizations. So we need to change the culture so that there is an expectation of a term limit.

    What would you consider a reasonable length of time for a person to hold a department chair position?

    Twelve years like the NIH is using is a very reasonable starting point. Many schools have in place five-year terms that are infinitely renewable. So it doesn’t have to be 12; it could be 15 years, or 10, but somewhere in that range. 20 years is probably too long.

    What would you say to someone who argues that 12 or 15 years is not enough time?

    That’s certainly a valid argument when considering very short terms, for example when considering five- or eight-year terms. There is a certain level of expertise that one gains, and certainly experienced leaders have value and have an important role to play for institutional memory. You also don’t want all of your leaders to turn over at the same time. It’s interesting, [since the Perspective came out], I have heard from colleagues or when I deliver talks, people say, “Well, you know I would have hated to have to end after five years.” And I laugh and say, “But I didn’t say five years. What about 15 years?” And they acknowledge, sometimes begrudgingly, that after about five years, they really had hit their stride. Perhaps they had been most effective between years five and 12 or five and 15, but a number have also acknowledged to me that after years 10 or 12, there have probably been diminishing marginal returns in terms of their performance. And ultimately, most of the leaders with whom I’ve spoken have agreed that perhaps bringing in a new perspective at some point in that 12- to 15-year range might be more valuable to the organization than keeping them in the positions, despite the great experience that they have gained — and especially if institutions thoughtfully designed ways for former leaders to continue to advise and mentor new leaders.

    Also, what they’ve said to me is that if they had come into their role with an expectation of a fixed term, it would have lit a fire under them to make their contributions while they had a chance.

    How do you change the culture where term limits are more acceptable?

    One way you change the culture is by changing the policy. On many university campuses, for instance in the college of arts and sciences, the chairship rotates among many deserving senior leaders. When there is the expectation of a term limit, people don’t feel ashamed when they return to being a “rank and file” faculty member. And many people have the opportunity to lead. If it’s the policy of the institution, then there’s no individual stigma at having had your term end, because everybody knows there was a term, and even if you’re the best leader in the world, it wouldn’t have been extended.

    You also argue in your Perspective that term limits alone are not enough. What do you mean by that?

    The big concern that has been raised is that although term limits are necessary, they are not sufficient to lead to a transformation of the demographics of our leaders. There is a real need to make sure our search processes are themselves not biased and that when we turn over chairs, we don’t replace them with individuals very similar to the people we had before. If we do, we don’t reap the full benefit of diversity and new perspectives.

    You mentioned earlier that your Harvard Medical School class had many superstars, both men and women. Why did the male superstars outperform the women superstars?

    In my opinion, it has to do with our evaluation of superstars. We look at the promise of a young man and say, “This is what he’s likely to achieve.” And we hire him for that leadership position based on his promise for the future. When we evaluate a woman in similar circumstances, we look at what she’s already achieved and we think about whether we can trust her with a leadership position in the future. It’s an unconscious difference, but it’s one we have to be very concerned about. Another thing we have to be very careful about is having consistent, transparent criteria for evaluating candidates. Say we have three criteria, and the woman meets two of the criteria and the man meets two of the criteria, and it must be that really the two that the man meets are the two that are the most important. We have to say up front if we are not going to weight all the criteria equally and if not, which are the ones that matter most to us.

    Why is gender diversity and diversity among underrepresented groups important at the senior leadership level?

    In an era when half the talent pool is female, and there are hopefully soon-to-be-growing numbers of other minority populations enrolled in medical school, it’s especially important for there to be fair equality of opportunity to reach senior leadership positions. There is a clear rights-based fairness argument — doing otherwise would fail to demonstrate respect for the fundamental dignity of human beings. That said, there are also a number of ends-based arguments about how diversity, equity, and inclusion are absolutely critical for medical schools to fulfill their missions. We often talk about the tripartite mission of medical schools: The pedagogical mission, the scholarly mission, and the clinical care mission. We need to have females in positions of leadership to teach and to serve as role models for young women. When you are a medical student and you don’t see anyone ahead of you who looks like you, it can be discouraging — that’s really not good for our pedagogical mission. We also have evidence that diversity influences the quality of research, because different questions are asked, different methodologies are used, and better results are obtained. Finally, there are some really interesting studies on the quality of clinical care that we provide. So, if a woman and a man present to an emergency department with symptoms of a myocardial infarction, we know that it doesn’t matter if the man is taken care of by a male or female physician. But if the woman is taken care of by a female physician, she does just as well as the male patient, and if the woman is taken care of by a male physician, she has worse mortality outcomes. And how well she does with a male physician depends on whether he has female colleagues. It’s remarkable. So, having women well represented at all levels, including leadership, may even be important to improve the quality of care that we deliver.