The full-time clinical faculty: what goes around, comes around

In his 1910 report entitled Medical Education in the United States and Canada, Abraham Flexner advanced an ideal model of medical education that included a university-based, full-time, salaried faculty whose time was devoted to teaching and research. This article traces the evolution of the "full-time" concept for clinical faculty and describes factors that have affected its implementation. Between 1910 and the 1930s, the full-time system for clinical faculty was implemented at a limited number of medical schools, but lack of financing made the system generally unworkable. The implementation of the "geographic" full-time concept during the 1940s to 1960s allowed faculty to be considered full-time while earning much of their income from clinical practice. Even then, there were concerns that medical schools would bring pressure on such faculty to increase their clinical activity for the purpose of supporting the institution. After the rise of private and public payers, clinical practice income came to be an explicit and increasingly important source of medical school revenue. This stimulated a significant expansion in the number of full-time clinical faculty over the next 40 years. In the 100 years following the Flexner Report, clinical faculty became "full-time" and "salaried," but not in the way Flexner imagined. Instead of deriving their salaries from the resources of the medical school, they are significantly contributing to institutional financing through their practice. Flexner's concern about the "distraction" of clinical practice interfering with faculty participation in education has come full circle, remaining a primary issue in medical education today.