Turnover among APM Members since 1971

Over the past decade, US medical schools andteaching hospitals faced unprecedented chal-lenges. These pressures include an increased

number of uninsured and underinsured Americans; ef-forts by the insurance industry to control health care coststhrough managed care and capitation; attempts byelected leaders to constrain the costs of publicly sup-ported health programs, including funding to academichealth centers; advances in medical science, technology,and therapies; governmental efforts to eliminate fraudand abuse in the health care industry; the intensificationof accreditation processes for medical schools, residencyprograms, and fellowship training; and increased expec-tations from organizations responsible for certifying, re-certifying, and credentialing physicians (1,2).

Not surprisingly, academic medicine struggled to re-cruit, hire, and maintain leaders during this time. In De-cember 2001, 23 medical schools (18.5%) were searchingfor a new dean, 29 (23%) for a new chair for the depart-ment of internal medicine, and 15.7% for a new chair forthe department of family medicine (J. Keyes, personalcommunication 9/24/02; M. Rule, personal communica-tion 9/25/02). For internal medicine, 11% of clerkshipdirectors, 14.3% of residency program directors, and17.2% of fellowship program directors turned over lastyear (3).

Founded in 1954, the Association of Professors ofMedicine (APM) includes as institutional members all ofthe chairs of departments of internal medicine at medicalschools in the United States and Puerto Rico that are ac-credited by the Liaison Committee for Medical Educa-tion. Including these 124 medical schools, APM currentlyrecognizes 126 institutions, considering Harvard MedicalSchool as three separate institutions: Beth Israel Deacon-ess Medical Center, Brigham and Women’s Hospital, andMassachusetts General Hospital (4). Also, APM includesaffiliate members who are physicians with “a faculty ap-pointment at the level of professor” and who have “ex-hibited leadership . . . in areas related to research, educa-tion, or clinical care” (4). Currently, the association has43 affiliate members.

Since 1971, APM has tracked turnover among chairs ofdepartments of internal medicine at US medical schools.By considering turnover among APM institutional mem-bers from 1971–2001, the authors examine the tenure ofthe leaders of the dominant department—in terms of ed-ucation, research, and patient care—for most US medical

schools (5). (Unfortunately, APM and other organiza-tions lack comparable data about the turnover ratesamong chairs of departments of internal medicine atcommunity hospitals.)

The number of departments of internal medicine atmedical schools has fluctuated over the past 30 years. As aresult, the number of APM institutional members in-creased from 96 in 1971 to 127 in 1989; in 1994, the totaldropped to 126, which is the current number.

To develop the data presented in this commentary, theauthors define turnover as occurring whenever the posi-tion of chair changes at an institution. For example, if achair steps down in May and an interim (or acting) chairis named, that constitutes one change or turnover; if a fullchair is named in August, that constitutes a secondchange or turnover. Similarly, if an interim chair isnamed full chair, it constitutes two changes (once whenthe initial chair stepped down and once when the interimchair became full chair).

Some may disagree with this definition for turnover.However, the authors maintain that each time a chairturns over (or the chair’s status changes from interim tofull), there is an effect on the faculty, staff, and the statusof the department. Judging the impact such changes haveon faculty, staff, departments, schools, teaching hospitals,or American medicine is beyond the scope of this com-mentary. Rather, the authors’ intention is to provide abenchmark about the turnover among APM institutionalmembers as well as to describe how these trends can pro-vide guidance to identifying, developing, and maintain-ing leaders in academic medicine.

Because the number of medical schools has fluctuatedsince 1971, the authors used the percent turnover of de-partment chairs rather than the absolute number ofchanges to analyze change (Table 1). For each decade (the1970s, 1980s, and 1990s), the data are shown in rollingaverages of 3, 5, 7, and 10 years (Table 2). The authorsbelieve that rolling averages provide a better perspectiveon general trends by stabilizing the turnover rates andaccounting for individual years of high or low turnover.

When a medical school is established (such as MarshallUniversity School of Medicine in 1976), the authors donot include the first chair of the department of internalmedicine as turnover (Maurice A. Mufson, MD, in thisexample). As a result, the authors use the number of med-ical schools in the previous year to calculate the percentturnover. To continue the example, Table 1 uses 117 for

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the number of schools to calculate turnover in 1976, in-stead of 120. By using 117, the commentary accounts forthe fact that three medical schools were established in1976 (Marshall University School of Medicine as well asthe Brody School of Medicine at East Carolina Universityand the University of South Carolina School of Medi-cine).

During the last 30 years, the turnover rate for full chairshas fluctuated from a low of 3% in 1993 to a high of 16%in 1990. For the past 7 years (1995–2001), turnover forfull chairs has been 10% or higher. On the whole, theturnover rate for full chairs fluctuates every year, but theaverages indicate a steady increase. The 10-year averagesshow only a slight increase overall (2%); but in 1981, theaverage decreased from 9% to 7%, and over the next 20years slowly increased by 4% to reach its current 11%.

The turnover rate for interim chairs has gradually in-creased since 1971. In part, this higher rate is due to a risein the number of interim chairs. In the 1970s, the average

number of interim chairs was 2.9%; in the 1990s, theaverage grew to 6.3%. The lowest interim chair turnoveroccurred in 1971, 1978, and 1986 at 2%. In 1982 and2001, turnover of interim chairs reached its highest levelat 10%. In 2001, 19 of the 126 APM institutional mem-bers were interim chairs.

When combined, the turnover rates for full and in-terim chairs indicate an increase in turnover over the last30 years. The 10-year averages show that in the last 15years, overall chair turnover is 15% or higher. In 6 of thelast 30 years, turnover reached above 20%; between one-fifth and one-fourth of all chairs changed in the last 3years (1999 –2001). Since 1970, the 10-year averages foroverall full and interim chair turnover have risen steadilyfrom 13% (in the 1970s) to 18% (in the 1990s).

Taken as a snapshot, the data are presented using thepercentage of full and interim chairs who changed eachyear (Figure). The Figure shows the lowest year of chairturnover (1986 at 6%) as well as the highest years (1991

Table 1. Average Turnover for APM Members (1971–2001)

Year Full chair turnover Interim chair turnover Total turnover % Total Medical schools Calculated schools

1970 961971 11 2 13 13% 100 961972 8 4 12 12% 103 1001973 11 3 14 13% 109 1031974 14 3 17 15% 111 1091975 15 5 20 18% 114 1111976 12 3 15 13% 117 1141977 11 4 15 13% 120 1171978 10 3 13 11% 123 1201979 9 6 15 12% 124 123

1980 6 9 15 12% 124 1241981 15 2 17 14% 124 1241982 9 12 21 17% 124 1241983 6 4 10 8% 124 1241984 7 5 12 10% 124 1241985 12 4 16 13% 125 1241986 6 2 8 6% 125 1251987 16 7 23 18% 125 1251988 11 10 21 17% 126 1251989 11 5 16 13% 126 126

1990 20 9 29 23% 127 1261991 18 9 27 21% 127 1271992 12 9 21 17% 127 1271993 4 10 14 11% 127 1271994 9 4 13 10% 126 1271995 14 7 21 17% 126 1261996 13 7 20 16% 126 1261997 20 8 28 22% 126 1261998 13 9 22 17% 126 1261999 17 8 25 20% 126 126

2000 17 11 28 22% 126 1262001 17 12 29 23% 126 1262002 11 6 17 13% 126 126

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and 2001 at 23%). A few times (in 1980, 1982, and 1993),the turnover rates for interim chairs are higher than forfull chairs. The past 3 years (1999 –2001) show the re-verse, with higher turnover among full chairs than in-terim. In each year, turnover for full chairs has leveled,whereas interim chairs have changed more often.

Each medical school is unique, and it is not surprisingthat turnover among APM members varies greatly frominstitution to institution. Ninety-five medical schoolshave existed continuously since 1971. Of these schools,four departments appointed as few as two chairs, the low-est rate of turnover at any institution: New York Univer-sity School of Medicine (Saul Farber, MD, and MartinBlaser, MD), Pennsylvania State University College ofMedicine (Graham H. Jefferies, MD, and Herbert Y.Reynolds, MD), University of Colorado School of Medi-cine (Gordon Meiklejohn, MD, and Robert W. Schrier,MD), and University of Texas Southwestern Medical

Center at Dallas (Donald W. Seldin, MD, and Daniel W.Foster, MD).

In contrast, five institutions have had at least 10changes since 1971: Columbia University College of Phy-sicians and Surgeons, Dartmouth Medical School, Me-harry Medical College, University of Rochester School ofMedicine and Dentistry, and West Virginia UniversitySchool of Medicine. If a department of internal medicinechanges chairs 10 times between 1971 and 2000, the av-erage tenure for an APM institutional member at theschool is 2.3 years.

Additionally, Hahnemann Medical College and theMedical College of Pennsylvania merged in 1994. Thestory of the merged medical school—which later becameMCP Hahnemann School of Medicine and is now DrexelUniversity College of Medicine—is well known (6). From1971 to 1994, 10 physicians chaired the Department ofMedicine at Hahnemann Medical College. Since then,

Table 2. Rolling Averages since 1971

Year% Fullchair

3 yravg

5 yravg

7 yravg

10 yravg

% Interimchair

3 yravg

5 yravg

7 yravg

10 yravg

%Total

3 yravg

5 yravg

7 yravg

10 yravg

19701971 11% 2% 13%1972 8% 10% 4% 3% 12% 12%1973 10% 10% 11% 3% 3% 3% 13% 13% 14%1974 13% 12% 11% 11% 3% 3% 3% 3% 15% 15% 14% 14%1975 13% 12% 11% 10% 9% 4% 3% 3% 3% 4% 18% 15% 14% 13% 13%1976 10% 11% 11% 10% 10% 3% 3% 3% 3% 4% 13% 14% 14% 13% 13%1977 9% 9% 10% 9% 9% 3% 3% 4% 4% 4% 13% 12% 13% 13% 14%1978 8% 8% 8% 9% 9% 2% 4% 4% 4% 4% 11% 12% 12% 13% 13%1979 7% 7% 8% 8% 8% 5% 5% 4% 5% 4% 12% 12% 12% 13% 13%

1980 5% 8% 8% 8% 8% 7% 5% 5% 5% 4% 12% 13% 13% 12% 12%1981 12% 8% 7% 7% 7% 2% 6% 5% 5% 4% 14% 14% 13% 12% 11%1982 7% 8% 7% 7% 8% 10% 5% 5% 5% 4% 17% 13% 12% 12% 12%1983 5% 6% 8% 7% 8% 3% 6% 4% 4% 5% 8% 12% 12% 11% 13%1984 6% 7% 6% 8% 8% 4% 3% 4% 4% 5% 10% 10% 11% 12% 13%1985 10% 7% 8% 8% 9% 3% 3% 4% 5% 5% 13% 10% 11% 13% 14%1986 5% 9% 8% 8% 9% 2% 3% 4% 4% 5% 6% 13% 13% 12% 15%1987 13% 9% 9% 9% 9% 6% 5% 4% 5% 5% 18% 14% 13% 14% 15%1988 9% 10% 10% 11% 9% 8% 6% 5% 5% 6% 17% 16% 15% 16% 15%1989 9% 11% 12% 11% 9% 4% 6% 6% 6% 5% 13% 17% 18% 16% 15%

1990 16% 13% 11% 10% 10% 7% 6% 7% 7% 6% 23% 19% 18% 17% 15%1991 14% 13% 10% 10% 10% 7% 7% 7% 6% 6% 21% 20% 17% 16% 16%1992 9% 9% 10% 10% 10% 7% 7% 6% 6% 6% 17% 16% 16% 16% 17%1993 3% 7% 9% 10% 11% 8% 6% 6% 6% 6% 11% 13% 15% 16% 17%1994 7% 7% 8% 10% 11% 3% 6% 6% 6% 6% 10% 13% 14% 16% 17%1995 11% 10% 10% 10% 11% 6% 5% 6% 6% 6% 17% 14% 15% 16% 17%1996 10% 12% 11% 10% 11% 6% 6% 6% 6% 7% 16% 18% 17% 16% 18%1997 16% 12% 12% 12% 11% 6% 6% 6% 6% 7% 22% 19% 18% 18% 17%1998 10% 12% 13% 13% 7% 7% 7% 7% 17% 20% 20% 20%1999 13% 12% 13% 12% 6% 7% 8% 7% 20% 20% 21% 19%

2000 13% 13% 12% 9% 8% 7% 22% 22% 19%2001 13% 12% 10% 8% 6% 23% 20% 16%2002 9% 5% 5% 13% 12%

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three physicians have chaired the department of medi-cine at the combined school.

On average, full chairs spent 5.66 years in their posi-tions, and interim chairs remained for 1.35 years from1970-1979. From 1980 to 1989, full chairs averaged 6.52years, and interim chairs averaged 1.22 years. In the1990s, full chairs averaged 5.70 years, and interim chairsaveraged 1.32 years. When combined for these 10-yearintervals, the average number of years full and interimchairs remained in their positions was 5.27 years in the1970s, 5.84 years in the 1980s, and 4.96 years in the 1990s.Moreover, one-half of current APM institutional mem-bers have been appointed since 1999.

Of APM’s current institutional members, 14 have beenchair for at least 10 years, nearly double the average forfull chairs in the 1990s. In December 2001, two APMinstitutional members remained in their positions sincethe 1970s: Dr. Schrier, who chaired the Department ofMedicine at the University of Colorado School of Medi-cine since 1976, and Felix M. Cortes, MD, who chairedthe Department of Medicine at Ponce School of Medicinesince 1978.

In addition to greater turnover rates, an increasingnumber of physicians now chair more than one depart-ment of internal medicine at a U.S. medical school during

their careers. In the 1970s, six chairs changed depart-ments, four changed departments in the 1980s, and 10changed in the 1990s. At this time, 10 chairs are leadingthe second medical school department in their career:Thomas E. Andreoli, MD, Donald J. DiPette, MD,Thomas D. DuBose, MD, Victor J. Dzau, MD, JeffreyGlassroth, MD, William L. Henrich, MD, John B.O’Connell, MD, Andrew I. Schafer, MD, Richard D. de-Shazo, MD, and Myron L. Weisfeldt, MD.

Finally, an increasing number of interim chairs are be-coming full chairs. In the 1970s, six interim chairs werenamed full chairs. This total tripled to 19 in the 1980s.The trend continued in the 1990s, when 32 interim chairswere named full chairs. At this time, 25 APM institutionalmembers were promoted from interim chair. Unfortu-nately, APM and other organizations lack data needed todetermine the number of full chairs who were hired fromwithin the institution but were not interim chairs.

There are several good reasons for promoting internalcandidates as department chairs. For example, some in-stitutions may groom the next generation of chairs, andthese leaders may better understand the institution’sunique culture. However, it is also less expensive to pro-mote an internal candidate than recruit an external one,particularly a physician currently chairing the depart-

Figure. Turnover of APM Members (1971–2001).

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ment of internal medicine at another medical school.Moreover, academic medicine lacks a systematizedmechanism for identifying, developing, and appointingfuture leaders (7). Few, if any, medical schools or teach-ing hospitals support programs that nurture the next gen-eration of chairs and other departmental leaders. Basedon the increase in internal promotions since 1971, it isimportant for academic medicine to support such pro-grams.

During the past decade, US medical schools and teach-ing hospitals faced difficult challenges. At the beginningof the 21st century, academic medicine continues to ad-dress these pressures, which have intensified. To make thesituation more threatening, academic medicine is begin-ning to face new pressures. These challenges include con-tinued changes in health insurance; the demand for high-quality care; the advent of electronic communication,which has increased public access to information aboutmedicine; more empowered patients, often as a result ofelectronic communications; an aging population that re-quires greater care and more expensive treatment; con-tinued advances in science that will transfer medicineinto a “postgenomic era”; and further progress in phar-maceuticals and technologies (8).

Although instability of leadership during a challengingtime has the potential to weaken an institution, appropri-ate changes in leadership can strengthen organizationsthrough enhanced resources, new ideas, and invigoratedcolleagues. A former APM institutional member ob-served, “The practical reality is that after seven to 10 years,most chairs have exhausted the ‘seed money’ they ob-tained at the beginning of their term. Even a beloved chairis unlikely to obtain the same amount of additional re-sources at that point that a new candidate can command”(B.S. Coller, personal communication 9/5/02).

Does increased turnover among the leaders of the mostdominant medical school department further strain aca-demic medicine? Is academic medicine strengthened orweakened when physicians chair departments of internalmedicine at more than one medical school during theircareers? Because academic medicine lacks programs todevelop the next generation of leaders, are departmentsdiminished as an increasing number of interim chairsbecome full chairs? Unfortunately, no data exist—fromany business sector, let alone the health care industry—toanswer these questions.

Based on available data, the authors encourage the ac-ademic medical community—particularly APM—to de-velop plans for addressing increased turnover, chairs wholead more than one department, and internal promo-tions. Without such strategies, medical schools andteaching hospitals will fail to lead American medicine inthe future.

Julia PearsonTod Ibrahim

Ms. Pearson is Membership Associate for APM and theAlliance for Academic Internal Medicine (AAIM), whichincludes APM, the Association of Program Directors inInternal Medicine, the Association of Subspecialty Pro-fessors, the Clerkship Directors in Internal Medicine, andthe Administrators of Internal Medicine. Mr. Ibrahim isExecutive Vice President of AAIM and the associations.This commentary reflects the authors’ opinions and notnecessarily those of AAIM or the associations.

ACKNOWLEDGMENTIn addition to Paul A. Hemmer, MD, the authors thank JeanineN. Bongers, Sheila T. Costa, Thomas B. Crist, and Maurice A.Mufson, MD, for their contribution to this commentary.

REFERENCES1. Ibrahim T. Academic internal medicine: challenges and opportuni-

ties—part I. Am J Med. 2000;108:525–529.2. Ibrahim T. Academic internal medicine: challenges and opportuni-

ties—part II. Am J Med. 2000;108:601–608.3. Number of new program directors for a specified period of time

(excluding combined programs) (7/1/2001– 6/30/2002). Accredita-tion Council for Graduate Medical Education Web site. Available at:http://www.acgme.org/adspublic/reports/programs_newpd_2002.html. Accessed September 24, 2002.

4. Association of Professors of Medicine’s Bylaws. (revised July 1,2002). Available at: http://www.im.org/APM/About/APMbylaws.htm. Accessed October 1, 2002.

5. Ibrahim T, Daley D. An alliance to unify academic internal medicine.Am J Med. 2000;108:94 –98.

6. Burns LR, Cacciamani J, Clement J, Aquino W. The fall of the houseof AHERF. the Allegheny bankruptcy. Health Affairs. 2000;19:7–41.

7. Sherwood L. Leadership: reflections on lessons learned in academiaand industry. Presented at APM Winter Meeting, February 28, 2002.

8. Goldman L. Key challenges confronting internal medicine in theearly twenty-first century. Am J Med. 2001;110:463–470.

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