Credentialled Into Irrelevance

According to a 2024 Academic Medicine analysis of AAMC Faculty Roster data, the share of clinical MD faculty who were tenure eligible fell from 59% in 1982 to 18% in 2022 – and at tenure-system schools, 72% of full-time MD clinical faculty were already non–tenure-track by that point. That collapse happened without any formal declaration that practitioners were less valuable; it happened because research output, grant capture and citation metrics function as the primary currencies of academic advancement, while active professional practice generates nothing legible for those ledgers. Peer-reviewed publications earn tenure; thousands of procedures do not. The more pressing question is why accreditation authority has not been pointed at faculty composition itself, and what professional formation costs when the people still doing the work are structurally defined as peripheral.

The Incentive Architecture

The modern research university was built to generate and validate new knowledge, so its hiring and promotion systems naturally reward the outputs that model can count: peer-reviewed publications, grant portfolios, citation indices and doctoral supervision. None of those metrics notice a neurosurgeon’s thousands of operations or a trial lawyer’s decades of courtroom work. As Lance Terada, presenter at a UT Southwestern Promotion & Tenure Workshop and chair of its Promotion & Tenure Committee, puts it, “The Currency For Promotion on The Tenure-Accruing Track: Scientific Publications; Grants; National & International Reputation; Teaching; Other” – with active practice nowhere on the list.

Accreditation frameworks in multiple professions reinforce that legibility logic. ABA law-school standards tie the definition of core full-time faculty to commitments that include teaching, scholarship, service and governance, embedding research expectations into the category accreditation treats as central. Association to Advance Collegiate Schools of Business (AACSB) business-school standards classify faculty into auditable qualification categories aligned with a school’s research expectations, while Accreditation Council for Graduate Medical Education (ACGME) common programme requirements for residency training describe an expectation of an environment of inquiry and scholarship, evidenced by peer-reviewed funding, publications, presentations and national roles. Across these documents, scholarship is not incidental; it is written into the definition of faculty quality.

When evaluation systems are calibrated to those signals, the form of appointment follows. Roles with security of position and promotion pathways flow toward staff whose work produces recognised scholarship, because that is what keeps a school inside its accreditation and ranking targets. Practice-grounded expertise – current, embodied and updated through ongoing professional responsibility – is more often channelled into adjunct, visiting and honorary positions that bring teaching hours without long-term cost or institutional voting power. The system does not have to devalue practitioners explicitly; it simply fails to reward what they uniquely supply.

The critique is not of research itself – it is of research metrics applied wholesale to formation roles, where the primary task is not knowledge production but professional readiness.

A Pattern Across Professions

In law, the tension is now surfacing directly at the accreditation boundary. In January 2026, the Texas Supreme Court issued an order, signed by all nine justices, ending the 43-year requirement that bar applicants hold a degree from an ABA-accredited law school. That move matters because ABA standards do more than prescribe courses; they draw status lines around faculty. Interpretation 402–2 states that a person who is “regularly engaged” in law practice is presumed not to be a full-time faculty member unless that presumption is rebutted through commitments that include research, teaching, service and governance, and historical standards such as Standard 404 and Interpretation 402–4 linked full-time status to scholarship responsibilities. The constraint does not ban practitioners from classrooms, but it structurally channels practice-heavy lawyers away from the core faculty category that accreditation treats as the institutional centre – which is the backdrop against which Texas’s decoupling opens space for alternative faculty models.

In medicine, accreditation has not been questioned in the same way, but the scale of training has changed dramatically. Between 2000 and 2025, 60 new US medical schools opened, and earlier this year 210 schools were operating, with at least six more announcing plans to launch programmes. Campuses offering Doctor of Osteopathic Medicine degrees grew from 19 in 1999 to 73, and D.O. programmes now educate roughly 30% of all medical students, in part to address a projected shortage of up to 86,000 physicians by 2036. This expansion increases the number of seats; built on research-oriented hiring and promotion systems, it does not automatically increase the number of practice-intensive clinicians with durable teaching authority inside those schools.

Engineering and business schools operate under their own accreditation regimes, but where faculty evaluation is similarly organised around auditable scholarly outputs and formal qualification categories, the same pressures are likely to apply. Direct longitudinal staffing data for those fields remains limited, so those parallels are structural inferences rather than measured trends – but structural inferences have a way of becoming self-fulfilling when no one is required to test them against outcomes.

The Appointment That Proves the Rule

There is a cautionary signal worth naming before the concrete case. A National Bureau of Economic Research (NBER) working paper titled “Do Tenured and Tenure-Track Faculty Matter?” analysed four-year institutions and reported that greater reliance on non-tenure-track instructional staff was associated with lower graduation rates in some institutional groupings. The results are correlational rather than causal, and they are not specific to clinician-educators – but they suggest that when teaching is concentrated in roles without security of position, institutions can lose the continuity and integration that help students progress.

Against that backdrop, the adjunct appointment of Dr Timothy Steel is structurally revealing. Steel serves as an Adjunct Clinical Associate Professor at the University of Notre Dame, teaching Masters in Medicine students while continuing to operate at high volume across both the private and public hospital systems in Sydney through St Vincent’s Private Hospital and St Vincent’s Public Hospital. The role formalises his contribution to education but sits outside a tenure-eligible pathway and carries no requirement for a publication record or grant portfolio – so under research-metric criteria, it is peripheral by design.

Steel’s clinical practice, by contrast, is central to the spine service at St Vincent’s. Since his consultant appointment in 1998 he has maintained regular operating lists in the private system and scheduled activity in the public hospital, with career-to-date totals reported on the St Vincent’s specialist listing of around 8,000 minimally invasive spine procedures and more than 2,000 complex spine operations such as disc replacement and fusion. The clinical environment that volume represents demands sustained technical authority – the kind built through ongoing responsibility for real patients, not through the scholarly outputs that promotion frameworks are designed to count. Clinical volume builds no publication record and earns no grant portfolio.

His adjunct appointment is not an anomaly or an oversight; it is what a rational university produces when publication and grant metrics define core academic value and intensive clinical work is treated as an external commitment. Replicated across an entire medical faculty, that logic becomes a structural test of how far research-metric incentives are reshaping professional formation itself.

What the Data Reveals

A systematic review and meta-analysis published in the Medical Journal of Australia on “rural pipeline” effects synthesised studies of how rural background and rural clinical training exposure relate to later practice in rural general practice. It found that both factors were associated with an increased likelihood of later rural practice, and noted that the duration and intensity of training experiences appeared to matter. That pattern turns outcomes tracking into a governance tool: by following where graduates actually work, institutions can see whether specific exposure structures are moving the workforce in the intended direction.

Professor Michelle Leech, Deputy Dean of the Faculty of Medicine and Health Sciences at Monash University, works in exactly that space where research-intensive activity and professional training meet. She represents the Monash School of Medicine within Medical Deans Australia and New Zealand Inc, the peak body for medical education and training across the two countries, in a faculty that is Australia’s sole member of the M8 Alliance of Academic Health Centres. Her responsibilities as a curriculum and faculty leader sit directly inside the tension the evidence describes: balancing hiring, promotion and workload decisions that reward publications and grants against the need to keep sustained frontline clinical practice embedded in core teaching roles. That’s not a comfortable position, and it’s worth naming why it matters here. A research-intensive faculty’s competitive standing and the practitioner-led teaching model it may be marginalising are not separate concerns – they’re expressions of the same design choices, and outcomes data is one of the few instruments that can make that trade-off legible rather than invisible.

Medical Deans Australia and New Zealand, as the sector’s outcomes-data steward, provides exactly that kind of longitudinal evidence. Its 2025 Medical Schools Outcomes Database National Data Report tracks how factors such as rural background and placement length shape graduates’ specialty choices and where they intend to practise. One finding is particularly stark: “Of those undertaking a rural placement for more than a year, 31 per cent expressed a preference for future practice in a rural or remote area.” For leaders such as Leech, that statistic makes clinical exposure – and who is structurally available to supervise it – a workforce lever; if intention shifts with the depth of practitioner-led placement, staffing models that marginalise practising clinicians from core teaching risk undermining the very pathways their own data identify as formative.

Redesign, Not Goodwill

Accreditation systems have already shown their reach. In June 2026, eight major accrediting, assessment and medical organisations committed in a single coordinated announcement to strengthening nutrition requirements across medical education, training and residency – demonstrating that when accreditors act in concert, professional schools respond at scale. That same mechanism could, in principle, be turned toward faculty composition rather than curriculum content alone. The same framework could, in principle, require that a defined share of core clinical teaching be delivered by clinicians with current practice responsibilities under appointments that carry genuine institutional standing.

A funding proposal from the University of Hawaiʻi system shows what it looks like when practitioner-teaching is built into institutional design rather than treated as a residual category. The Board of Regents has requested $3,724,600 for a Health Science and Healthcare Interdisciplinary Workforce Initiative that would add 18.5 clinician-faculty full-time-equivalent positions across five health-sciences units, with roles that combine training future health professionals and providing direct patient care in areas such as cancer care, neurology, dementia, behavioural health and addiction medicine. By tying budget, headcount and service planning to clinician-faculty roles, the proposal treats practice-grounded teaching as core infrastructure, not a discretionary add-on.

Redesigning professional education around that principle would not mean abandoning research metrics or weakening academic standards. It would mean revising hiring, promotion and accreditation architectures so that the safest institutional choice is to give practice-grounded teachers durable standing at the centre of programmes rather than precarious status at the edge. Professional schools will keep producing impressive credentials – the question is whether any of the clinicians who signed off on them were still in the room with a patient last week.