Cooke, Molly MD; Irby, David M. PhD; Debas, Haile T. MD
The Academy of Medical Educators at the University of California, San Francisco (UCSF), was established in 2000 to (1) foster excellence in teaching, (2) support and reward medical teachers and educators, and (3) promote curricular innovation. The concept was born in the early phase of an extensive curricular reform; the initiative is intended to recognize the critical role of outstanding teachers with adequate time to teach and a viable academic career path in medical education. In this article, we describe UCSF's Academy of Medical Educators: its mission, membership criteria, selection process, programs and activities, and early impact.
DESCRIPTION OF THE ACADEMY
Over the 1990s, the school of medicine at UCSF faced several challenges: the high degree of managed care penetration in the Bay Area produced the kinds of pressures on clinical faculty members to be highly productive, with associated reduction of time for activities in support of other aspects of the academic mission, that have been widely described elsewhere.1 Other challenges were unique to our situation: the UC–Stanford merger and subsequent de-merger consumed monetary and psychological resources, and left faculty shaken and uncertain about their future. While a number of basic science departments had already made the decision to provide salary support for core teachers, clinical departments remained dependent on voluntary efforts of full-time salaried faculty members, with salary support going only to key administrators of departmental educational programs. By the late 1990s, clinician–educators found themselves expected to cover their entire salaries and associated overhead through their clinical efforts while volunteering for the teaching of medical students and house officers, if the teaching activities could be made to fit. A number of faculty members in this situation wondered out loud whether the clinician–educator career track was viable.2
In 1997, the new vice-dean for education (DMI) was expressly charged with reinvigorating the undergraduate medical curriculum at UCSF. After a faculty-driven process in which a mission statement for the school of medicine educational program was developed and guiding principles and explicit outcome objectives were enumerated, he appointed two committees to generate contrasting visions for UCSF's new curriculum. One committee was charged to design a curriculum for the 21st century building on current strengths and addressing areas of weakness. The second committee, which came to be known as “Blue Skies,” was instructed to re-envision medical education at UCSF. This committee, chaired by an outstanding teacher in the Department of Neurology, rapidly arrived at the conclusion that curricular elements and pedagogical approaches were of secondary importance; rather, its members recommended the establishment of a cadre of dedicated teachers and outstanding medical educators, at least some of whom would receive salary support for their teaching. Through the efforts of this corps, to be called the Academy of Medical Educators, junior teachers would be inspired and supported, and a program of medical education befitting the 21st century would be brought into being. A proposal to create such an academy was presented at the school of medicine leadership retreat in January 1999 to the enthusiastic reception of department chairs and other school leaders. In March 1999, the dean (HTD) announced that he would dedicate the entirety of funds coming to UCSF to support the academic mission from UC–Stanford Healthcare, the corporation representing the merged medical centers, to the Academy of Medical Educators. This amount, $1.25 million per year with a like amount going to Stanford University School of Medicine, was received for two years before the dissolution of the merger. In addition, the dean announced his intention to commit additional funds to establish a matched endowed chair program for outstanding teachers and educators, jointly funded by the dean's office and the host department. In August 2000, the academy's first director (MC) was appointed.
Selection Criteria and Membership
UCSF's Academy of Medical Educators is a membership organization. From September 2000 to May 2001, an initial group of stakeholders—including the director, the vice-dean for academic affairs, the vice-dean for education, basic science and clinical department chairs, and several outstanding teachers representing a variety of disciplines and UCSF teaching sites—developed an application and selection process. Building on the work of Simpson, five categories of educational activity were defined; outstanding performance in any one of the five could qualify a faculty member for Academy of Medical Educators membership.3 The type of evidence expected in support of an application in each category is detailed in Table 1. The time frame is limited to five years preceding application; documentation in each category is restricted to two pages. A complete application also includes a candidate's statement of educational philosophy and anticipated contributions to the missions of the academy, and a letter of support from the candidate's department chair. For applicants applying in Advising and Mentoring and Educational Leadership and Administration, the academy solicits an “impact statement,” a structured comment on the contributions of the candidate. Letters of support solicited by the candidate are expressly discouraged.
Applications are screened by a selection committee. Well-prepared packets with clear documentation of strong teaching performance are sent for outside review by a panel of national experts in medical education, in the educator's portfolio, and/or in faculty development. Three or four outside reviewers who are generally not personally acquainted with the candidate review each packet. The committee then meets to select members, incorporating the assessment of the outside reviewers. In the first round of selection, completed in September 2001, 24 members were chosen from an applicant pool of 50. These 24 successful candidates represented four basic science departments and ten clinical departments. The second round of applications, completed in September 2002, added 13 new members, representing one additional clinical department and one affiliated educational program.
Expectations of Members
The term of academy membership is five years; however, terms are renewable after review comparable to the initial application. Members of the Academy of Medical Educators are expected to continue to teach medical students and to perform at the same outstanding level in one or more areas of educational activity that justified their initial selection. In addition, members are expected to participate in activities in support of the mission of the academy. Annually, each academy member submits a one-page form detailing his or her educational activities and academy service. Cessation of medical student teaching, a decline in quality of teaching and educational work, or inadequate service to the school through academy activities will result in non-renewal.
Perquisites and Benefits of Academy Membership
Members of UCSF's academy do not receive salary support simply by virtue of selection to the academy. The bulk of salary support available to faculty members through the academy is distributed through the program's innovations-funding program, a project-driven internal grant-making initiative available to academy members and non-academy members alike. This project-based, rather than membership-based, approach was recommended by the academy's initial advisory board and, perhaps surprisingly, was enthusiastically endorsed by the large majority of the first cohort of academy members. However, those selected to the academy do benefit in at least two ways. First, selection certifies the faculty member as an outstanding teacher and educator whose accomplishments have impressed not only UCSF colleagues but also a panel of national authorities. A number of academy members report that they are now turned to by their department leaders when issues of educational consequence arise. Second, selection to the academy appears to advantage its members in the promotion process. Of the 24 initial academy members, 11 were under consideration for a merit advancement (progress within a rank) or promotion from assistant to associate or associate to professor in the year following their selection. Four of the 11 advancements were proposed ahead of time and consequently were “accelerations”; three proposed accelerations were successful. Thus 27% of advancements of academy members were accelerated compared with the school-wide rate of 5% across all faculty appointments. At UCSF, accelerations have been almost always a consequence of outstanding research accomplishment and/or part of a retention package. Thus, selection to the Academy of Medical Educators has, at least in our early experience, made available to accomplished teachers an important reward mechanism previously available only to researchers.
Access to matched chair funding is a third potential benefit for academy members. The dean has set aside $1 million per year for the academy's first five years to establish partially endowed chairs in support of key educators. At UCSF, $500,000 is required to minimally endow a chair. In the academy's matched chair program, an interested department proposes an establishment of a matched chair, committing at least $250,000 to be complemented by $250,000 from the dean's fund. The proposal is reviewed with a particular emphasis on the department's contribution to the school's educational mission and previous chairs awarded. Once a chair is established, a search is conducted jointly between the department, the academy, and the Office of Medical Education. Applicants are restricted to academy members or, in the case of outside candidates, to those who qualify for academy membership. Salary support derived from the matched chair program is intended to relieve the incumbent of a salary-generating activity unrelated to education, usually clinical service, freeing time for creative work in education. At this time (early 2003) nine matched endowed chairs are established or are in the process of establishment in eight departments. Again, the endowed chairs have a five-year term but may be renewed with the concurrence of the academy and the sponsoring department. Several departments plan to actively rotate their chairs to create opportunities for talented young educators.
Programs and Activities
The innovations-funding program, the largest line item in the academy's budget, is an internal grant-making program that supports development of new curricular elements, focused faculty development undertakings, comparison of pedagogical approaches, and innovative approaches to learner assessment. The faculty–student committees overseeing UCSF's curricular transformation, the Essential Core Steering Committee (years 1 and 2) and the Clinical Studies Steering Committee (years 3 and 4), identify areas of curricular need; funding priorities are refined through discussion between academy leadership and the associate dean for curriculum. A request for proposals is issued twice a year: initiatives of high priority are identified in the call, but faculty are encouraged to submit in non-prioritized areas as well. This program funded six projects totaling $144,721 in 2001–02 and 14 projects totaling $297,570 in 2002–03. Seventy-seven percent of expended funds are in the form of faculty salary supporting release time for creative work in education, particularly program development. The innovations-funding program provides one-year grants. Faculty members may submit “competing renewal” proposals, but the funds are expressly not intended to support routine course or clerkship operations, nor are they intended to decrease departmental support for teaching faculty. Representative projects supported through the innovations-funding program are Preparation of Prosections to Support a Shortened Anatomy Course in the first year, Students as Teachers: Improving Instruction in Physical Examination in the second year, Three Clerkship Knowledge Integration and Assessment in the third year, and Improving Competence in Long-term and Palliative Care in the fourth year. This program is exceptionally popular among the teaching faculty and is growing rapidly; the program has provided an average of $7,672 of salary support for each of 28 non-academy members and an average of $12,436 salary support for ten academy members.
The Academy of Medical Educators exists to foster excellence in teaching and to support and reward teachers; this aspect of the academy work is organized by the faculty development working group. In 2001–02 the group focused on enhancing faculty members' understanding of the educator's portfolio and encouraging its use by all whose contributions in education are better represented in portfolio than in curriculum vitae format. In 2002–03 the academy initiated a mentoring program for junior faculty members built around peer observation of teaching. Faculty at the three core teaching hospitals are being introduced to the program through a half-day workshop that explicates the promotion process at UCSF, presents in brief the educator's portfolio, and describes the purpose and process of peer observation and feedback in teaching. This program is conceived of as a service to junior faculty who desire this level of collegial support of their teaching rather than as a remedial undertaking.
A fundamental strategy for enhancing the status of and rewards accruing to teachers and educators in a competitive research-oriented academic environment is to strengthen the scholarship of their work.4 UCSF's academy was exhorted to vigorously pursue this approach at our inaugural “Celebration of New Members” in 2001 by the president of the Carnegie Endowment for the Advancement of Teaching. To this end the Academy organized UCSF's first “Education Day” in early 2002. This event was enthusiastically received; 50 abstracts were submitted by faculty members, house officers, and medical students. Most were presented as posters; five oral presentations displayed the range of pedagogical, curricular, and programmatic innovation, from the use of Web-based dynamic cardiac imaging to demonstrate concepts in first year physiology to the description of an innovative American Board of Internal Medicine–acceptable “family track” for residents in internal medicine with heavy family responsibilities.
Building on the requirement that projects supported through the academy's innovations-funding program will be presented at UCSF's Education Day, the academy has instituted the expectation that results from the innovations-funding projects will be suitable for national presentation and/or publication. To that end, the academy's scholarship working group, in cooperation with experts from the Office of Medical Education, works with faculty members preparing innovations-funding proposals to ensure that a strong evaluation component is part of every proposal. Quarterly “education scholarship clinics” provide assistance in project design, data analysis, preparation of manuscripts, and presentations to all faculty who desire to increase the scholarly dimensions of their work. The academy intends to expand these activities to include assistance with the identification of appropriate funding sources for educational initiatives and grant-writing clinics.
Governance, Administration, and Budget
The academy's director reports to the vice dean of education and, because the academy is a resource for faculty in the school, cooperates closely with the vice dean for academic affairs. The work of the academy is conducted by the members, organized into six working groups. The chairs of the working groups meet monthly with the director as an executive committee. The academy members meet together quarterly; one of the meetings is a day-long retreat to plan for the coming academic year. An advisory committee meets three times per year and provides the perspectives of stakeholders, including department chairs, medical students, house officers, very junior faculty, and volunteer faculty.
The director's position is designed to use 50% of that individual's work effort at UCSF. The academy is also supported by a full-time staff administrator and an administrative assistant. Because the academy, a young organization, is growing and adding programs rapidly, operating expenses have increased substantially in each six-month period since August 2000. As previously described, the innovations-funding program is by far the largest line item. It is anticipated that there will be a stable annual operating budget of $500,000.00 to $650,000.00 in the near future. The dean has committed $500,000 a year in support of the operations of the academy for its first five years. Despite the initial reservations of UCSF's development office, the academy has proved to be a relatively attractive focus for some donors. The director's position is supported by an endowment, and donors have expressed interest in establishing an unmatched chair to be funded entirely through the academy in support of an outstanding educator who teaches about the patient–doctor relationship and in supporting a fellowship program through which junior faculty who do not yet qualify for academy membership can strengthen their scholarship.
IMPACT OF THE ACADEMY
It is early to make definitive statements about the impact of UCSF's Academy initiative. The innovations-funding program has clearly promoted curricular innovation and has enabled faculty members to contribute to the transformation of UCSF's undergraduate medical education programs. The identification of curricular priorities in the calls for innovations-funding proposals has allowed the academy to work in cooperation with faculty curriculum oversight committees and has allowed the Office of Medical Education to direct the program development energies of the faculty without stifling creativity. The six projects funded in 2001–02 have resulted in six national presentations and two publications to date, suggesting the innovations-funding program is allowing faculty members to establish themselves as scholars as well. The apparent positive influence of selection to the academy on faculty members' promotion reviews has been described. In addition, department chairs are taking an active interest in the candidacy of their faculty. After the announcement of the selection of new members in 2002, a number of department chairs requested appointments with the director to discuss how the applications of unsuccessful candidates could be strengthened and to request advice about the mentoring of more junior faculty who are potential academy aspirants. It will be difficult in a complex environment to isolate the impact of the academy on the quality of teaching at UCSF, but that program is clearly seen as enhancing the status of outstanding teachers; those of us involved in the academy look forward to having a more direct effect through the peer-teaching observation and feedback program.
There are several academies and academy-like structures in medical schools throughout the country. (See a description of such a program at Harvard Medical School in this issue of Academic Medicine.) It is inevitable and proper that these structural approaches to enhancing the status of teachers in schools of medicine and to improving teaching will take a unique shape at each school. Decisions that we believe have contributed to the success of the academy at UCSF to date are several. First, after considering a requirement that successful candidates for academy membership perform at an outstanding level in three or four of the five areas of educational activity, the initial stakeholders elected to accept candidates who are excellent teachers of medical students and whose contributions are outstanding in one or more of the five defined areas. As we look back on this decision, it seems clear that a three-out-of-five or four-out-of-five requirement would have excessively advantaged course and clerkship directors and disadvantaged outstanding teaching faculty without responsibilities in educational administration. Second, we believe that external review of portfolios considerably enhanced the credibility of the selection process and also benefited the academy members, in that outside reviewers have regularly been willing to write external letters in support of promotions for candidates whom they reviewed positively. Third, the open access to the academy's innovations-funding program has generated much good will on the part of teaching faculty who are not academy members; they otherwise might have been inclined to regard the academy as an elitist organization further privileging a minority of faculty who often already have some support for their teaching efforts. Fourth, the inclusion of non-academy members on all of the academy's committees and working groups, with the exception of its executive committee, has encouraged the academy to be attentive to the needs and concerns of the broad range of the teaching faculty in the school of medicine and has enhanced understanding of the goals and philosophies of the academy. Fifth, the academy has established a very constructive working partnership with the education deans and the Office of Medical Education. The academy leadership recognizes that, to be maximally useful to the school of medicine, the activities of the academy must be coordinated with the work of the Office of Medical Education and with the goals of the curricular oversight committees. Reciprocally, the Office of Medical Education appreciates that the academy will have the greatest impact on teaching and education at UCSF if it is allowed to function with considerable independence as an organization of UCSF's most outstanding teachers in service to the school.
UCSF's Academy of Medical Educators is just three years old. In that time, its leaders have developed a rigorous selection process that includes external review and conducted two rounds of application, resulting in the selection of 37 members. The academy has undertaken programs of internal grant making, funding 20 curriculum enhancement projects and providing over $340,000 in salary support for faculty release time.
Challenges remain. UCSF's academy is focused, by direction of the dean, on undergraduate medical education. Worthy teachers whose efforts are directed at residents are not selected. This emphasis puzzles some external reviewers and discourages some outstanding teachers. The academy is able in the short term to run a very successful and popular innovations-funding program. Securing this program for the long term will require an endowment of $8–10 million; it is not clear that this level of support is attainable for a program of this type. Finally, it remains unclear whether an organizational structure such as an academy, even if it is able to promote significant change in the culture of academic health centers, will be sufficient to motivate the sustained voluntary donation of the thousands of faculty teaching hours essential to medical education.
Future plans are to build upon and extend the academy's current work, to establish a number of new programs, and to secure the program's future through endowment funding. The academy will continue to solicit applications for membership on an annual basis and to work with department chairs to help them mentor their junior faculty academy aspirants. However, we anticipate that the Academy of Medical Educators at UCSF will remain highly selective, with a membership that constitutes less than 5% of the faculty of the school of medicine. The academy's leaders intend to explore other forms of affiliation with the academy that would be appropriate for volunteer faculty, faculty members in the other health professions schools on the UCSF campus, and, perhaps, medical students, residents, and fellows with a strong interest in teaching. The program will continue the innovations-funding program and is in the early phases of considering initiating a second program, the transformation-funding program, through which faculty members would receive a more significant level of support, perhaps 25% to 30% for two years, to undertake projects of a more ambitious or radical nature than the innovations-funding program can support. From $350,000 to $400,000 is anticipated to be devoted annually to these two programs over the next four years, assuming that the academy continues to receive a large number of meritorious proposals. The program will significantly expand its mentoring activities, creating a program of intensive formal mentoring in addition to the informal mentoring that all academy members currently provide. There are plans to establish a fellowship for junior faculty members. As currently conceived, this would consist of mentored involvement in one of the academy's five areas of educational activity, with a two-year stipend provided for modest release time for the fellow, allowing promising junior faculty to build a record of accomplishment in teaching and education.
UCSF's Academy of Medical Educators has had a strong connection to the Academy of Medical Educators at Harvard from the outset. Both academies have worked with colleagues at Baylor College of Medicine, Mayo Medical School, and Mt. Sinai School of Medicine. The UCSF program intends to continue to collaboratively develop a national network of academies and academy-like organizations. Perhaps in another decade, these efforts will have a noticeable and positive effect on the quality of medical education in the United States.