Tenure, defined as a guaranteed permanent employment after a probationary period, especially as a teacher or professor, is a relatively new concept in academia, although not to the current generation of academics. The American Association of University Professors codified the modern academic tenure system in the 1940s, primarily for the protection of academic freedom. After a probationary period of demonstrating the ability to make continuing important contributions to the academic institution, the professor would be granted a guarantee of continuing employment and salary that could not be removed except for serious ethical or criminal violations or complete cessation of work for a significant period of time. The goals of establishing tenure were to assure freedom of teaching and research and to guarantee a sufficient degree of economic security to make the profession attractive. It is important to remember that tenure is a local benefit. The specific meaning of tenure depends on the institution that grants it. It does not automatically follow you from one institution to another, and its requirements and benefits vary from institution to institution. Neurosurgeons beginning an academic career often ask if it's worth seeking to become tenured. There are two aspects to the answer to this question. The salary guarantee is probably not an important factor for the academic neurosurgeon. Most medical schools set guaranteed salaries at levels comparable to humanities professors at the same rank. Lifetime clinical salary guarantees are almost unheard of. The salary guarantee is most important to those with primarily non-clinical responsibilities and salary not generated from clinical activity. The guaranteed position is potentially of some greater value, but academic freedom issues are often not a consideration in medical school appointments, although in some circumstances it might be important. The bottom line is that for most academic neurosurgeons, the granting of tenure does not provide financial security. And unless there are unusual considerations, the protection of academic freedom is not a major concern. Tenure granted at one institution does not guarantee the grant of tenure if you move along to another, although it probably increases the chances of the new institution granting it. For most neurosurgeons, tenure is primarily a badge of honor. Promotion, on the other hand, is important to neurosurgeons who plan on a lifetime academic career. It usually means an increase in pay. It is a recognition of continuing positive contributions to your department and institution. It is often a requirement for continuing employment in the medical school. And typically, when you change institutions, you retain at least the same rank as you had at the prior institution. Therefore, promotion is important to the career academic neurosurgeon. How do you get promoted? Well, you demonstrate your value to your department and your institution. There are many ways to do this through outstanding clinical service, by doing outstanding research, and by being an outstanding educator. But excelling at any of these requires focus. The area of focus most people think of for academic neurosurgeons is basic laboratory research, although it is probably a minority of academic neurosurgeons who achieve either promotion or tenure on this track. For the faculty member focused on basic research, the standard tenure track works best. The evidence required for promotion on this track includes developing an independent research laboratory with sustained funding from national sources that support the laboratory, substantial publications in high-impact basic science journals, a record of national and international speaking engagements in the chosen area of research, and support from nationally and internationally known scientists in the relevant field. It is increasingly difficult for neurosurgeons with a clinical practice to be competitive with full-time PhD scientists in basic science research. This is becoming a less common promotion track in academic neurosurgery. Most medical schools have several tracks for academic physicians that capture the essential elements of the focus of the faculty member's career. They have different names at different institutions, and I will use the names from my own institution, but similar tracks are available in most medical schools. For the faculty member focused on excellence in clinical service, the master clinician track works best. The master clinician develops a national or international reputation in a specific area of clinical neurosurgery. The evidence required for promotion on this track includes a national for associate professors or international for professors referral practice, a national or international record of invited speaking engagements, national or international invited teaching engagements, and clinical publications. For the faculty member focused on excellence in neurosurgical education, the science of education track works best. The evidence required for promotion on this track includes educational publications, successful course directorships, development of novel curricula that are adopted at home and at other institutions, and residency program directorship is a common qualification. For the faculty member focused on excellence in developing new devices or operations, the Science of Innovation track works best. The evidence required for promotion on this track includes publications documenting novel and successful operations, publications documenting novel and successful devices, and the awarding of patents. For the faculty member focused on excellence in synthesizing neurosurgical evidence who focuses on interpreting and clarifying existing knowledge, the science of integration track works best. The evidence required for promotion on this track includes publication of high quality systematic reviews and meta-analyses and well-designed clinical studies. The bottom line is that the best way to get promoted and develop a degree of job security is to make yourself difficult to replace by being an excellent neurosurgeon, a good citizen of your department, medical school, hospital, profession, and community, and a good mentor to colleagues, students, trainees, nurses, and all those who help you. These are general principles about promotion and tenure. Each individual situation is unique. They must be adapted to the special features of the institution in which you practice. There is no one best profile of the successful academic neurosurgeon. You adapt to your institution and it adapts to you.

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