14 Apr 1996
As an assistant professor-turned-private practice dude, this is my take on academic rank in US schools.
INSTRUCTOR: In most schools, you get this right out of residency and hold it for a short time, usually until you pass your boards. However, in schools which fancy themsleves as better than the other schools, you may be held in this rank longer (or brought in as "assistant instructor"), based on the biblical Doctrine of Original Inferiority or something.
ASSISTANT PROFESSOR: You get this rank in most schools if you're Board-certified. You have to work really hard and take on whatever thankless responsibilities are shoveled out to you by the chairman. You are basically involved in a game with the school administration. Your aim is to 1) stay out of trouble, and 2) trim down the number of thankless responsibilities to the point where you have time to work on your bibliography. The administration's job is to keep you so loaded down with garbage that you can't possibly write any papers, so they can hold the promise of promotion over you as long as possible and get the most work out of you they can. The only ways you can win the game are 1) actually write the papers and get them published, 2) get a huge grant (which is impossible unless you started out de novo with big-time connections -- Catch-22), or 3) do the undesirable garbage jobs so well and so seamlessly that it would be more of a hassle for the school to replace you than to just give up and promote you to...
ASSOCIATE PROFESSOR: If you were sufficiently conditioned by the school to observe its work ethic, their investment in you may pay off big time. You continue to work hard and do your share of thankless jobs, all the while you are becoming better known in your field and are actually getting quite good at what you do. However, things can go sour from the school's standpoint if you wake up one morning and realize that you really could get by with a lot less work and lapse into a chronic "sorry, I don't do windows" mode.
PROFESSOR: We always refer to these as "full professors" to distinguish them from the much more numerous members of inferior ranks, sort of like "full colonel" (to distinguish same from "lieutenant colonel") and "full president" (to distinguish same from "First Lady"). There are three ways to get to the rank of professor: 1) leave your institution as an associate professor and go to another one which is even more desperate for faculty than the one you left (an example of the "prophet is not without honor but in his own land" theorem), 2) get a huge grant (see above), or 3) survive at least three fired chairmen (this is based on Darwin's little-known principle of Survival of the Most Harmless). As with associate professors, you can follow one of two behavioral paths. You can become 1) a beloved icon of competence, wisdom, and responsibility, or 2) an amorphous mass of akinetic, inert protoplasm. Sociopaths are quite good at following the latter path, in that they don't have any burdensome conscience to weigh them down.
To get promoted you have to do what your boss, the chairman, expects of you. However, even if you do this, it is unlikely you will get promoted. There are two reasons for this. 1) The chairman who set out to formulate your goals with you when you were hired will probably not be the chairman when you finally accomplish those goals. Moreover, it is very likely that your current chairman will not think any goals set forth by his or her predecessor are worthwhile (the main qualification for getting a chairman's position is being as dissimilar to the previous chairman as possible). 2) The chairman doesn't do the promoting. The promoting is done by the Dean, who has no idea who you are (the so-called "Montgomery Burns-Homer Simpson Phenomenon"). The Dean relies on the advice of the Promotions Committee. The main qualification for being on the Promotions Committee is that none of its members know anything about the quality of the work performed by the promotions candidate, nor do they have sufficient background in the candidate's field to be able to judge that quality.
But nonetheless, an academic career in medicine is still a worthwhile pursuit, and I highly recommend it to anyone of quality who is not averse to suffering a few rather large bumps on the road to professional success.