The Association of American Medical Colleges' (AAMC) Council of Academic Societies (CAS) has had a long-standing interest in scholarship as it relates to research, education, and service, the three-legged stool traditionally defining the activities of medical school faculty. Members of the CAS, representing faculty in the AAMC, play a major role in the education of medical students, graduate students, residents, and postdoctoral fellows in addition to their commitments to basic and clinical research and to clinical and community service. The interest of the CAS in scholarship in medical schools has been stimulated by plenary sessions and small-group discussions of scholarship at our annual meetings over the past five years. The invited speakers and discussants have explored scholarship as it relates to the actual “work” of medical school faculty in today's rapidly changing health care environment, which has had a major impact on academic medical centers. These continuing conversations have suggested to the CAS members that a closer examination of scholarship as defined and practiced by medical school faculty would make an important and timely contribution to our understanding of the scholarly activities of these faculty.
Continuing discussions of scholarship in the CAS, with input from both the Group on Educational Affairs and the Group on Faculty Affairs of the AAMC, have led to an increasing awareness of and respect for the thought-provoking writings of Ernest L. Boyer and Charles Glassick, of the Carnegie Foundation for the Advancement of Learning. Two monographs, Scholarship Reconsidered: Priorities of the Professoriate, by Boyer, published in 1990,1 and Scholarship Assessed: Evaluation of the Professoriate, by Glassick, Huber, and Maeroff, published in 1997,2 have made seminal contributions to our understanding of scholarship and its evaluation in American universities. These authors' broad definitions of four different types of scholarship reflect the actual “work” done by faculty and are applicable to all disciplines, including those that have large service components, such as medicine. These writers have defined four areas of scholarship —the scholarship of discovery, the scholarship of integration, the scholarship of application, and the scholarship of teaching. Other academic disciplines have already begun to examine how scholarship in these four areas might be appropriately rewarded. Representatives of 20 discipline-based associations gathered at the invitation of Robert Diamond of Syracuse University to consider what a broader definition of scholarship in their fields might entail. Historians, chemists, mathematicians, and representatives of other disciplines proposed definitions of scholarship to encompass the full range of professional work performed by scholars in their respective fields. These discussions are summarized in the monograph entitled Recognizing Faculty Work: Reward Systems for the Year 2000, by Diamond and Adam.3 Clearly, a review of scholarship as applied to the professional activities of medical school faculty is timely.
The CAS Scholarship Task Force has responded to this challenge by soliciting a series of papers that applies the principles of scholarship outlined by Boyer to medical school faculty. These articles, written by experts in academic medicine, most of them faculty members and administrators at medical schools, are published together in this special theme issue of Academic Medicine. The CAS hopes that the ideas put forth in these articles will produce a continuing dialogue as faculty and administrators at medical schools reflect on the value of these different forms of scholarship, their application by medical school faculty, and their contributions to the individual missions of each medical school and teaching hospital. In addition, these articles will stimulate continuing discussions that will define equitable methods for the continued assessment of the scholarly accomplishments of medical school faculty.
To show how research has become the major force in evaluating faculty in today's universities, Boyer1 traced how the focus of the academy has evolved throughout the history of the United States, resulting in the current emphasis on research. The first American universities and colleges founded in the colonial states were largely concerned with teaching and focused on educating their students for future civic and religious leadership. The goal of these early universities was clearly to enhance learning. This emphasis began to change in the 19th century as the United States developed from a collection of weak individual states into a strong nation. The focus in higher education increasingly emphasized technical training and agriculture. The importance of practical training in agriculture was further accentuated by the Morrill Act of 1862, which donated federal land to each state for the support of education in both liberal arts and practical training for the emerging agricultural and industrial revolutions.
This transition in American universities from a focus on learning to a focus on service continued into the 20th century as universities and colleges continued to educate students who not only would serve society but would reshape it. Despite this emphasis on service as a major component of universities during the 19th century, many scholars who had studied in Europe were greatly influenced by the research orientation of German universities. Consequently, in many prestigious universities, basic research gained greater importance, while research and graduate education became the model for the modern university. It should be noted, however, that in most universities at the beginning of the 20th century research and graduate education were the exception rather than the rule. Indeed, the land-grant universities continued to take pride in their educational orientation towards service.
In the middle of the 20th century, the Depression, followed by the Second World War, brought about a dramatic change in academic life, partly as a result of the national push for scientific collaboration during the war effort in projects such as the development of the atomic bomb. The role of the federal government in the funding and development of collaborative projects in the scientific community during the war and early post-war years eventually led to the founding of the Office of Scientific Research and Development in the federal government. Academics increasingly looked towards Washington and the federal government to obtain grants to support a growing research enterprise. Starting in the late 1950s and continuing into the 1960s, the focus on scientific research and training in universities increased dramatically as a consequence of the early successes of the Soviet Union in the race towards space exploration. As the emphasis on research and graduate training in American universities continued, scholars began to identify their research and teaching with their disciplines rather than with the academy as a whole. Indeed, the definition of a “scholar” became synonymous with university professor.
This increasing focus on, and identification with, specific disciplines in the academy continued as increasing emphasis was placed on research. It reached the point that young faculty members who were hired to teach were nonetheless evaluated for promotion based almost entirely on their abilities to perform research. Increasingly, professors were expected to conduct research and publish results. Decisions for promotion and tenure were largely based on the tangible and easily quantifiable research publications. Consequently, young assistant professors began to focus their attention more intensely on their research while giving lip service to their role in undergraduate education. This dichotomy between research and teaching continued into the late 1980s and early 1990s. At that time, various groups, including state legislatures, parents of college students, and academicians who relished teaching, began to question the emphasis on research in the university and to stress the importance of the faculty as teachers. In their monographs published in the 1900s,1,2 Boyer and Glassick concluded that a new vision of scholarship was required to clarify the academic missions of American universities and to develop faculty reward systems that reflected the realities of contemporary academic life. A brief summary of Boyer's definition of scholarship and its assessment is provided in the first article of this series, “Boyer's Expanded Definitions of Scholarship, the Standards for Assessing Scholarship, and the Elusiveness of the Scholarship of Teaching,” by Charles E. Glassick, PhD, senior associate of the Carnegie Foundation for the Advancement of Teaching.
THE FOUR AREAS OF SCHOLARSHIP
The four different categories of scholarship defined by Boyer begin with the familiar scholarship of discovery, or “original research,” which is the most common definition of scholarship used by universities in promotion and tenure policies. Defining and establishing criteria to evaluate the three additional areas of faculty activities proposed by Boyer as scholarship does not minimize the importance of discovery and research in academic life. Discovering new knowledge in the quest for deeper understanding of the world is critical to the scholarly ambience of the university. The inquiring minds of researchers, whether physicists, economists, or clinicians, contribute to the intellectual environment of the university. Through these researchers, students are exposed to the process of inquiry that includes asking pertinent questions and establishing hypotheses to be tested. In addition, both undergraduate and graduate students are often motivated and inspired by the passion brought to intellectual pursuits by persons actively involved in research. Creativity, as exemplified by the contributions of the bench scientist, the composer of music, or the epidemiologist, is crucial to the academy and society. The importance of the scholarship of discovery should not be minimized as new models of scholarship are recognized, described, evaluated, and rewarded.
For faculty in medical schools, increasingly the scholarship of discovery involves research collaborations between basic and clinical scientists. These interactions are important for translating the basic research that provides an understanding of the underlying causes and progression of disease into innovative clinical practice. Two recent reports—one from the Clinical Research Summit, entitled Clinical Research: A National Call for Action,4 and the other the Report of the AAMC Task Force on Clinical Research, entitled Ensuring the Future of Clinical Research,5 —have stressed the need for continued emphasis on clinical research in medical schools. To give only one example, complete sequencing of the human genome will provide the impetus for the continued generation of new information about genomics and proteomics. This burst of knowledge of basic biological phenomena will lead to new approaches to individualized care and require continued emphasis on basic and clinical research in medical schools.
The articles in this issue of Academic Medicine discuss in detail Boyer's definitions of the three other areas of scholarship, which have not been widely applied to faculty activities and evaluation in medical schools. The second area of scholarship defined by Boyer is the scholarship of integration, which involves stepping back from a narrow area of research to search for connections between discoveries obtained by different approaches or even from varied disciplines. Integration becomes true scholarship when novel insights, both interpretive and interdisciplinary, are discovered. In this issue, Dale Dauphinee, MD, executive director of the Medical Council of Canada, and Joseph Martin, MD, dean of Harvard University's Faculty of Medicine, have addressed this aspect of scholarship in “Breaking down the Walls: Thoughts on the Scholarship of Integration.”
The third area of scholarship defined by Boyer is the scholarship of application, which involves building bridges between theory and practice and encompasses the service functions of academics. This aspect of scholarship basically asks how knowledge can be used in a practical situation. As described earlier, the main function of universities in the 19th century was equipping their students for service to society. Today, service in universities does not generally involve providing service to the larger world, but is more often narrowly focused on fulfilling campus needs or in the simplest case performing necessary departmental chores. Service as a scholarly activity has not been valued in universities, in part because of the difficulties in evaluating service as scholarship. In the practice of medicine, however, new intellectual understandings may evolve during the actual act of application itself and may include developing innovative approaches to, or systems of, patient care. Eugene Shapiro, MD, professor of pediatrics, and David L. Coleman, MD, professor of medicine, both at Yale University School of Medicine, have addressed this aspect of scholarship in “The Scholarship of Application.”
The last area of scholarship defined by Boyer is the scholarship of teaching, which involves communicating one's knowledge effectively to students. Knowledge gained through basic research, by integrating data from different disciplines, or by applying novel techniques is meaningful only when communicated and understood by others. To be an effective teacher, one must be an active learner, constantly keeping abreast of one's discipline and integrating this knowledge into a coherent whole. When teaching is raised above the general level to that defined as the scholarship of teaching, the benefits serve both to educate students and to excite other scholars. Members of the AAMC Group on Educational Affairs, with Ruth-Marie E. Fincher, MD, vice-dean for academic affairs at the Medical College of Georgia, as senior author, have addressed this aspect of scholarship in “Scholarship in Teaching: An Imperative for the 21st Century.”
The discussion of these different approaches to scholarship should not be interpreted as suggesting that a faculty member should be narrowly focused on one area of scholarship. Clearly, the activities involved in the different areas of scholarship are not mutually exclusive, and a faculty member might be concurrently involved in more than one. Examination of the four areas of scholarship suggests that each area has significant overlap with one or more of the other areas. Also, it is clear that faculty members' scholarly work may change emphasis at different times throughout their careers. Despite the possibility of defining scholarship in areas other than research, the promotion and tenure policies of many universities continue to stress that every beginning assistant professor should first concentrate on research and demonstrate competence as a researcher as a condition for promotion to a tenured position. After achieving this goal, however, a faculty member might decide to concentrate on other activities such as integration, teaching, or application of knowledge. Whatever activity becomes the focus of the faculty member, scholarship should continue to be a major component in the new activity and used as an evaluation tool for the faculty member.
Acceptance of the expanded definitions of scholarship described by Boyer will clearly be far easier in the academy than the difficult task of establishing methods for assessing scholarship in these different areas. The major emphasis of the monograph Scholarship Assessed: Evaluation of the Professoriate, by Glassick et al.,2 is to describe a systematic approach to the evaluation of all four areas of scholarship. To obtain uniformity in the evaluation of scholarship, Glassick cites six standards common to the assessment of all manner of scholarly work: clear goals, adequate preparation, appropriate methods, significant results, effective presentation, and reflective critique. These standards for intellectual activities constituting scholarship are universally accepted in all fields. The article by Glassick in this issue of Academic Medicine provides additional discussion and clarification of these standards. One outstanding characteristic critical to the assessment of all areas of scholarship is the importance of presentation to others. Discovery of new knowledge or integration of previously published information into a novel synthesis does not contribute scholarship unless it is communicated to others. For example, experimental results from scientific experiments that remain forever in a laboratory notebook have no intrinsic value. Similarly, teaching and applied scholarship are also incomplete unless communication to peers and other scholars occurs in addition to presentation to the usual audience of students, colleagues, or the public. To be considered scholarship, every scholarly accomplishment needs be shared with and judged by other scholars.
In the past decade, many medical school faculties and deans of faculty affairs have been questioning and struggling with the evaluation criteria used in the promotion of medical school faculty. This problem has become most acute in assessing the scholarly activities of clinical faculty, who are increasingly required to devote more of their time to clinical practice. The pressure in many medical schools for clinical faculty to generate their own salaries and to support the institution by their clinical earnings has resulted in a critical lack of time for these faculty to perform the necessary scholarship of discovery, integration, or teaching. Many schools have addressed this problem by developing alternative, often non—tenure-track, pathways for the evaluation and promotion of clinical faculty. Despite the need for clinical faculty to generate income, clinical research and teaching remain essential activities in today's medical schools and have necessitated a reexamination of the criteria for promotion of clinical faculty to include scholarly work.
To learn how different medical schools have approached the problems of evaluating faculty, the CAS Scholarship Task Force turned to members of the Group on Faculty Affairs to obtain case reports from schools that have experimented with novel promotion policies. Some medical schools had applied the Boyer criteria to their promotion policies. Others had developed innovative methods of fostering excellence in teaching, especially for clinical faculty. The task force selected five case reports describing new policies for evaluation and promotion for publication in this issue. The titles of these reports indicate the wide range of experiences encountered in evaluating scholarship in medical schools: “Revising Appointment, Promotion, and Tenure Procedures to Incorporate an Expanded Definition of Scholarship: The University of Kentucky College of Medicine Experience,” by Lois Margaret Nora, MD, JD, associate dean for academic affairs and administration, and colleagues at the University of Kentucky; “Adoption and Failure of the “Boyer Model” at the University of Louisville,” by Laura Fran Schweitzer, PhD, associate vice president for health affairs/faculty affairs, University of Louisville Health Science Center; “Valuing Education Scholarship at the Medical College of Wisconsin,” by Deborah E. Simpson, PhD, associate dean for educational support and evaluation, and colleagues at the Medical College of Wisconsin; “Defining Scholarship at the Uniformed Services University of the Health Sciences School of Medicine: A Study in Cultures,” by Eric Marks, MD, associate dean for faculty affairs at the Uniformed Services University of the Health Sciences; and “The Mayo Clinic's Clinician—Educator Award: A Program to Encourage Educational Innovation and Scholarship,” by Thomas R. Viggiano, MD, MEd, associate dean at the Mayo Medical School. To reiterate, the CAS hopes that these articles will stimulate continuing discussions among faculty and administrators as they wrestle with the problems of evaluating scholarship in medical schools.
VIEWS OF ADMINISTRATORS
Finally, the CAS Scholarship Task Force was interested in learning the views of both university and medical school administrators on scholarship in the medical school. Schools of medicine generally are not freestanding institutions and must comply with the promotion and tenure policies of the parent university. Hence, establishing and evaluating new areas of scholarship for the medical school faculty must conform to university rules. An alternative approach would be for the parent university to recognize the problems involved in assessing clinical scholars and accordingly revise the university guidelines for promotion provided that scholarship and its evaluation in areas other than research were clearly defined. The article by Robert L. Barchi, MD, PhD, provost, and Barbara Lowery, EdD, RN, associate provost for faculty affairs, at the University of Pennsylvania, entitled “Scholarship in the Medical Faculty from the University Perspective: Retaining Academic Values,” provides insights into how scholarship in the medical school is viewed by the university. The final article, by Wendy Levinson, MD, chief of the Section of General Internal Medicine at the University of Chicago, and Arthur H. Rubenstein, MBBCh, dean and executive vice president at the Mount Sinai School of Medicine, entitled “Integrating Clinician—Educators into Academic Medical Centers: Challenges and Potential Solutions,” provides a view of scholarship from the office of the dean of the medical school. In this article, they address in depth the problem of evaluating clinical faculty so heavily involved in clinical practice that it affects their ability to perform scholarly work.
The Scholarship Task Force of the AAMC CAS solicited articles by leading academicians in medical schools describing the scholarship of integration, the scholarship of application, and the scholarship of teaching as applied to medical school faculty. The five case reports describe different approaches to applying these principles to the evaluation of faculty activities in medical schools. Overviews of scholarship of medical school faculty from the perspectives of the provost of the university and the dean of the medical school are also included. The CAS hopes that these articles and case studies will provide a valuable tool for explaining the role of scholarship in evaluating the activities of medical school faculty while providing a stimulus for continuing discussions of this important area of academic life.
Council of Academic Societies Task Force on Scholarship
Chair: Diana Beattie, PhD
Professor and Chair, Department of Biochemistry
West Virginia University School of Medicine
Society representing: Association of Medical and Graduate Departments of Biochemistry
Shelley Bader, MLS, EdD
Associate Vice President, Educational Resources
George Washington University
Society representing: Association of Academic Health Sciences Library Directors
Debra DaRosa-Creek, PhD
Professor, Department of Surgery
Northwestern University School of Medicine
Society representing: Association for Surgical Education
Dona Harris, PhD
Director of Academic Development
Brody School of Medicine
East Carolina University
Society representing: Society of Teachers of Family Medicine
Philip Liu, MD
Professor and Chairman
Department of Anesthesiology
UMDNJ—New Jersey Medical School
Society representing: Society for Education in Anesthesia
L. Gabriel Navar, PhD
Professor and Chairman
Department of Physiology
Tulane University School of Medicine
Society representing: Association of Chairs of Physiology Departments
Barbara Schuster, MD
Chair, Department of Internal Medicine
Wright State University School of Medicine
Society representing: Association of Program Directors in Internal Medicine
Ex officio: Paul McCarthy, MD, CAS Chair, 1999–2000
Professor of Pediatrics
Director, Section of General Pediatrics
Yale University School of Medicine
Society representing: Ambulatory Pediatric Association
Ex officio: George F. Sheldon, MD, CAS Chair, 1998–1999
Professor and Chairman
Department of Surgery
University of North Carolina School of Medicine
Society representing: The American Surgical Association