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Providing Diverse Trainees an Early and Transparent Introduction to Academic Appointment and Promotion Processes

Introduction The growth in number of medical schools and increased numbers of faculty tracks have combined with evolving criteria for promotion to trigger a call for greater transparency of academic appointment and promotion processes. Most vulnerable to confusion about these changes are first-generation and diverse medical students and residents, the upstream pipeline of the academic medicine workforce. Diverse medical students have expressed diminished interest in academia because of perceived obstacles in appointment and promotion processes. Methods This workshop was designed to utilize didactics and career reflection exercises to help trainees learn: (1) how to define core terms related to academic appointment and promotion processes, (2) how to compare data elements for different CVs and portfolios, (3) common steps in submitting a promotion package, and (4) that they can immediately begin to document content for academic CVs, portfolios, and promotion packages. Results One hundred forty-five diverse participants completed an evaluation at eight conferences across the U.S. More than 90% strongly agreed or agreed that the aforementioned objectives were met. Participants commented that the workshop was “illuminating,” was “very informative,” and “provided an inside look of how faculty are evaluated.” Results showed an immediate impact on participants' self-reported confidence to negotiate appointment and promotion processes. Discussion Increases in self-rated confidence to negotiate appointment and promotion processes may help sustain trainees' interest in becoming future faculty. Further monitoring will be needed to determine if early exposure to these concepts improves probability of seeking, obtaining, and maintaining appointments.


Introduction
Since 2010, there has been significant growth in the number of allopathic medical schools in the U.S., with the opening of 14 new schools, while another eight are now candidates seeking credentialing from the Liaison Committee on Medical Education. The rapid proliferation of medical schools has been accompanied by an increased number of faculty tracks and evolving criteria for promotion in the areas of education and service. The increased number of tracks has brought on modifications to promotion criteria, triggering a call for greater transparency about academic career paths and evaluation processes

Original Publication
for promotion of faculty. With these changes, development of a robust upstream pipeline for the academic medicine workforce deserves careful attention, particularly given chronic underrepresentation of diverse populations on academic medicine faculty. This workshop was designed to present diverse faculty facilitators who have been successful in academic medicine as models for the diverse learners participating. Although it is impossible to mirror all diverse identities represented within the audience, it is possible to have diverse presenters talk about their own journey in medicine coming from their own unique backgrounds. Honest disclosure of minority status will enhance the impact of each facilitator presenting this workshop. Finding the most competent and effective faculty for the academic medicine workforce will become more feasible with greater dissemination of information regarding academic career paths and promotion criteria. Currently, medical trainees often lack formal or structured instruction on how to become faculty members. In addition, many medical students and residents report hearing discouraging or inaccurate career information from ill-informed or disgruntled faculty.
Institutions are working to provide greater transparency and technical assistance in the promotion process to ensure recognition of all contributions and to guarantee equitable promotion, yet diverse faculty may be most vulnerable. Faculty development efforts must consider the continued challenges faced by women in reaching senior leadership positions, the underrepresentation of racial and ethnic groups on faculty, and the potential for faculty to be promoted based on their lesbian, gay, bisexual, transgender, and alliesrelated (LGBTA-related) work. For these groups, unclear criteria for promotion and a lack of understanding of institutional culture can greatly impair not only their recruitment but, more importantly, their retention.
Throughout their educational journey, health professionals are expected to describe and document their academic and extracurricular performance and achievements, and to showcase their most significant accomplishments. Documentation within a given format provides applicants with an early understanding of the metrics used to evaluate their achievements, their career trajectory and path, and their fit for a particular program or institution. Premedical students summarize this information on resumes and their American Medical College Application Service (AMCAS) application, medical students on their CVs and their Electronic Residency Application Service applications, and residents on their CVs and their first employment applications, while faculty continually update their CVs and portfolios. Some components are similar (e.g., documenting scholarship), while others are unique to the training level (e.g., AMCAS application-describe one's most meaningful experience; educator portfolio-educator's philosophy).
A portfolio, as a collection of an individual's work, can facilitate narrative reflection, self-assessment, and goal setting.
For mentors, the CV or portfolio is a crucial aid in reviewing and guiding mentees in their professional journey. Quality mentoring can be particularly beneficial for recruitment, retention, and promotion of women and faculty of color. A stronger appreciation of how resumes, CVs, and portfolios are different yet build on one another can strengthen an applicant's success along his/her educational journey and eventual faculty appointment and promotion. Good habits throughout this evolving journey are essential. A health professional benefits by sustaining and building upon these good habits while applying a continuing structure across evolving roles. At the very core of that structure are thoughtful preparations and formation of consistent organizational habits with an intentional focus on documenting those components needed for advancement.
In a recent study of diverse medical students' awareness of academic medical careers, only one-third of respondents agreed or strongly agreed that they knew which personal activities and achievements are needed for a career in academia. Several participants were dissuaded from pursuing academia because of perceived obstacles in the promotion process, including a lack of transparency regarding promotion criteria and policies, lengthy time to achieve tenure, uncertainty about nontenure lines, and the existence of "a good old boys club." Others were concerned that activities such as teaching, mentoring, and community service would not be valued in the promotion process. A comparable study among American Indian students and faculty also highlighted concern regarding transparency in the promotion process, while for LGBT students and faculty, there is fear of bias against LGBT-related work and scholarship in the promotion process. A better understanding of which activities to document, and the promotion process in general, may foster greater interest in academia as a career for all trainees.
In the winter of 2015, the Building the Next Generation of Academic Physicians (BNGAP) group developed a set of workshops to promote diverse medical students' and residents' awareness of academic medicine careers. A BNGAP curriculum committee comprising 25 diverse trainees and educational leaders from across the country helped to create and/or review the workshops. Four committee members with experience in faculty affairs and the academic promotion process were responsible for developing this particular workshop to introduce trainees to what is involved in appointment and promotion as academic medicine faculty. The six-step Kern model was applied by the curriculum committee members as a framework for the design, implementation, and evaluation of the workshops.
1. Problem identification and general needs assessment: The committee performed this step via a literature review and input from trainees and faculty. 2. Targeted needs assessment: This assessment was conducted by means of a mixed-methods study of trainees' perceptions of academic medicine careers, including facilitators and barriers to academic career intent, and preferred career development activities. 3. Goals and objectives: Based on the literature review, results of the mixed-methods study, and committee member input, the goals of the workshop are to help participants define the terms portfolio, faculty tracks, and promotion package; compare data elements for different CVs and portfolios; outline steps in submitting a promotion package; and list tips for documenting content for academic CVs, portfolios, and promotion packages. 4. Educational strategies: To stimulate an active learning environment, the material was presented as an interactive workshop incorporating reflection, mapping, and sharing of career goals via large-and small-group discussion. Small groups have a positive effect on learning performance by promoting learner motivation and authenticity, as well as active participation, purposeful activity, and face-to-face contact. 5. Implementation: The 1-hour workshop was administered during an academic medicine career development conference for medical students and residents. Participants and speakers were from the hosting medical school and from nearby academic health centers. This venue was chosen because it afforded students opportunities for career-specific learning, skill development, positive learning environments, and networking with individuals beyond their own academic health centers. 6. Evaluation and feedback: Each conference participant was asked to complete a questionnaire and evaluate the workshop design and content.
This workshop has been implemented in the context of a larger curriculum but can also be implemented as a stand-alone module. The workshop includes core concepts regarding developing academic CVs and portfolios, and navigating the promotion process. As each institution has its own tracks and promotion practices and policies, facilitators should consider how their respective institutions differ from the material presented. At a minimum, students should leave the workshop with an appreciation of the importance of maintaining accurate records of their activities in a timely fashion and aligning their documentation with best practices of their current or future institution.

Methods
Each workshop presented at BNGAP conferences was initially drafted by a team of experts in academic medicine. This workshop on the academic promotion process was drafted by four individuals: two holding academic dean appointments within faculty affairs, a vice dean, and a dean for diversity and inclusion. The presentation was developed to increase awareness of the importance and method of developing and maintaining a CV, portfolio, and promotion package and thereby bring greater transparency to the process.
Ideally, this workshop should be implemented with 30-50 participants to facilitate open communication among a smaller cohort of learners. Cofacilitation by two or more academic affairs leaders from diverse backgrounds is ideal but may not always be possible. If it is not possible to identify diverse cofacilitators, facilitators can be asked to explain why they seek diverse candidates for faculty positions and the importance of faculty diversity for reducing health disparities. Specifying the areas of diversity that the facilitators are trying to enhance in their home institutions can be an important message for the audience.
A goal of this workshop was to increase understanding in three target areas: (1) the ability of trainees to navigate the process of finding an academic appointment, (2) the ability of trainees to develop and build a CV, (3) and the ability of trainees to understand how to achieve promotion after academic appointment. is lack of transparency regarding the faculty promotion process." The following questions were only asked postworkshop: • This workshop can be implemented with medical students and/or residents (and even junior faculty). The preferred facilitator would be a faculty member with an MD or DO degree on the medical educator track. However, academic appointments and promotions are often overseen by basic scientists or other faculty. Experience in academic appointment and promotion processes is the critical qualification needed by workshop leaders. Optimal presentation involves two facilitators modeling discussions and sharing complementary observations in the presentation. The presentation can be done by a single facilitator. With two facilitators, we recommend dividing the different sections of the presentation equally in an integrative and collaborative fashion. The optimal length of this workshop is 60 minutes; however, it can be tailored based on resources. For example, the workshop can be lengthened to 1.5 hours to allow participants to review and discuss each other's CVs. In this case, the optimal number of participants would be 40-50, thus permitting a safer, more engaged space for participants to ask questions. Participants can be situated at small or large tables to facilitate small-group discussion during the workshop (e.g., PPT Slide 26: Mapping Your Career Goals).

Results
This workshop was implemented at eight regional conferences. All 145 medical student and resident participants completed an evaluation form for this specific workshop. The 145 respondents were a diverse sample attending training programs in 21 different states (Table 1). In addition, our facilitators were also diverse. There was a total of 10 presenters (six single presenters and two pairs of cofacilitators) at various levels in their careers: assistant professor (one), associate professor (two), and full professor (seven). All facilitators were faculty with experience in faculty affairs, and all but one held a senior faculty affairs appointment (seven with a dean's title and two with a vice chancellor title).
Learners from the eight regional conferences responded to the following questions, pre-and postworkshop ( Table 2): 1. "How much confidence do you have in your ability to navigate the tenure and promotion process in academic medicine?" This was answered by 94.5% (137 out of 145) of learners. Overall, confidence increased from pre-to postworkshop.  To what extent do you AGREE with the following statement: There is lack of transparency regarding the faculty promotion process. 3.53 3.18 .000 The paired-samples t test was applied to assess a statistically significant change in confidence (p < .05).
Postworkshop, learners from the eight regional conferences responded to the question, "To what extent do you agree that the workshop learning objectives were met?" Most agreed or strongly agreed that the objectives had been met. Their responses are summarized in Table 3.
Comments for the workshop were overall positive, with a few suggestions for improvement. We have organized unique participants' comments by the workshop learning objectives. Responses to the question, "What did you like about this workshop?" included the following: • Objective 2: Define the terms portfolio, faculty tracks, and promotion package.
• "I think it was a helpful presentation on the goals and roles of different types of promotion." • "Their presentation was helpful in defining the steps towards academic medicine." • "I learned how to outline my CV and what type of faculty tracks exist." • "Well defined terms, it helped me demystify the academic promotion system." • "Specific info that I have not been exposed to in the past." • "It was helpful to see a more big picture view of the career process in academic medicine." • "Very helpful in illuminating what happens after residency and the different tracks available." • Objective 3: Compare data elements for different CVs and portfolios.
• "I enjoyed that the workshop introduced the variability in the approaches in achieving different levels of academic scholarship." • "Discussing the different faculty tracks as well as how to build/update a competitive CV." • "Very informative on how portfolios differ from CV." • "CV information and breakdown is very, very helpful." • Objective 4: Outline steps in submitting a promotion package.
• • "Outlined the key elements to laying out application materials for career advancement." • "I had no idea how promotion works, so it was great info." • "Love the advice that if you are in an institution that is going a different direction than your interest, it's ok to jump to 'another bus'." • Objective 5: List tips for documenting content for academic CVs, portfolios, and promotion packages.
• "I liked learning about the CV and what needs to be included. I also appreciated learning about the process of promotion at the institutional level." • "This was a very helpful road map to a career in academic medicine." • "This workshop outlined the information very well and was very informative in terms of demonstrating the basics of career planning and promotional guidance." • "I enjoyed having an inside look and true understanding of how faculty members are evaluated." • "I liked the explanation of how various tracks work, as well as the advice about developing/maintaining the CV." • "This presentation set off several alarms in my mind, reminding me to pull information together that I temporarily let go due to convenience, specifically my teaching evaluations." Evaluation also revealed areas in which participants felt changes might enhance the impact. Responses to the question, "What suggestions do you have to improve this workshop?" included the following: • Objective 2: Define the terms portfolio, faculty tracks, and promotion package.
• "Tailor the lectures more to where the audience is at in the academic medicine process by engaging where our interests lay. For example, if a large majority are interested in tenure, then talk longer about this or if most of us are just concerned about getting into an academic position out of residency, tenure can be deemphasized." • Objective 3: Compare data elements for different CVs and portfolios.
• "I wasn't completely sure what a CV exactly entailed. A suggestion would be to include a CV copy in the packet." • "More focus on CV and what those look like, how they work would be great." • "This was a great workshop. I loved the info & insight. More insight on CV building for the specific trades would be beneficial." • Objective 4: Outline steps in submitting a promotion package.
• "I found this lecture to be slightly overwhelming because we were thinking about applying for tenure/etc. when many of us weren't even sure what we are going into for residency." • Objective 5: List tips for documenting content for academic CVs, portfolios, and promotion packages.
• "I would have liked more to learn about how to draft a CV as a first year med student."

Discussion
BNGAP is now in its third year of presenting conferences aimed at increasing interest in academic medicine among trainees from groups traditionally underrepresented in medicine. We have been successful in drawing trainees who come from underrepresented ethnic groups. Women and sexual minority trainees have also been well represented, including LGBT individuals. While no long-term follow-up is yet available to monitor the impact of the conferences on numbers entering and succeeding in academic medicine, short-term results appear promising.
Evaluations of this workshop document its effectiveness in increasing trainee awareness of the components required for a successful career as a faculty member. Participants reported significant increases in self-rated confidence regarding their ability to negotiate the appointment and promotion processes as a faculty member in the future. They also reported an increase in their confidence regarding being able to update their CVs, and a few requested examples of CVs of faculty in different tracks. A common response from learners, however, was surprise that some of what they do as medical trainees ought to be documented as content for an early CV. Overall, participants noted an increased understanding of the processes involved in promotion. Such a shift in perception suggests an increase in sense of self-efficacy around what they would need to do to be successful in a faculty role.
There are important limitations to be considered. Perhaps the greatest limitations of this work as scholarly inquiry are that: (1) the intervention is not randomized, (2) long-term outcomes are not gathered or evaluated, and (3) facilitators vary in their diversity and in their comfort in discussing and sharing personal diversity. Coming to one of these workshops may select out those most drawn to academia to begin with. Only random assignment of those seeking to sign up would allow an adequate test of the strength of the intervention. At the same time, randomizing access to this training cannot be defended ethically: Refusing admission on the basis of randomization would be an unjustifiable exclusion of many whose lives have been marked by unjustifiable lack of access to opportunity in the first place. Optimally, the best test of this intervention would be strong repeated evaluations over time, to see if those who attend workshops show a higher rate of entering academia than those who share their demographic background but do not attend the workshops. Long-term evaluation of outcomes needs to address whether there are increases in the rate of entry into academia and in the rate of retention in academia.
Since the workshop attendees were diverse medical students and residents, the BNGAP conferences appear to have potential as a tool to demystify the promotion process. There are unique considerations to providing this as an effective workshop. First and foremost, we ask that participants think beyond their immediate next step and consider their longer career trajectory. This process requires a greater level of directed insight and thus facilitates informed career decision making. Another potential limitation is that the intervention may be delivered by individuals who are not conversant in discussions of diversity. To ameliorate that possibility, our PPT and discussion guide pose questions for facilitators to address: "Please share what makes you diverse, discussing both stigma assigned to aspect(s) of your background as well as important sources of privilege in your life. Please share what drew you to presenting today: How is your commitment to diversity a part of that? Invite questions from the group." To optimize the learner experience, we select facilitators who have experience in diversity work and who have gone through promotion of at least one rank (e.g., instructor to assistant professor on a clinicianeducator track). Facilitators who are affirming, inspirational, and engaging have the potential to be viewed as role models and can help attendees increase their interest in a career in academia. Given the workshop's potential to heighten discourse concerning diverse trainees' perceptions of the appointment and promotion processes, we have added the following learning objective: Describe diverse trainees' perceptions of the academic appointment and promotion processes. A few participants suggested that assessing awareness of and questions about the academic promotion process at the initiation of the workshop could help direct the facilitators' focus and the length of discussion on certain topics covered (e.g., tenure). In the PPT and discussion guide, we have added such a probing question to Slide 6, which features published quotations specifying trainees' concerns with the lack of transparency regarding faculty promotion and tenure processes.
We worked with conference host leaders to identify diverse facilitators who had a track record of excellence in teaching and mentoring diverse trainees. Additional experience in managing academic personnel is ideal for this workshop, particularly in recognizing and being committed to the critical importance of attracting and advancing a diverse faculty. Awareness that faculty diversity is critical to optimizing quality of care for multiple populations underlies programmatic attempts to increase that diversity. Although prior mentoring work is not technically critical to this role as facilitator, committed performance as a mentor or sponsor of trainees likely marks an ideal presenter.
Additionally, our emphasis in seeking presenters/facilitators at BNGAP conferences has been to bring forward role models among women as well as underrepresented minority (URM) and LGBTA-related groups. In prior research, medical trainees from such groups recognized a lack of concordant role models and mentors when considering academic careers. While the audiences for these workshops included many trainees from diverse backgrounds, it is critical to note that no one was excluded. The inclusion of everyone who wished to participate has been a core feature of these workshops, with the goal of creating an inclusive community for all. Targeting only women, URM, or LGBTA-related groups would work against the experience of inclusion in the workshop and thus against the ultimate goal of increasing the diversity and inclusion of faculty.