Institutions committed to medical education have historically spent an inordinately small amount of time preparing their faculty members for their responsibilities as teachers. Academic health centers (AHCs) have often perceived teaching as an add-on role, with the assumption that talents exhibited in the clinical or research realm would be sufficient qualification for this teaching responsibility. Fortunately, this perception is changing, allowing a growing appreciation for the work of the clinician–educator and an increasing commitment to accepting excellence in teaching as appropriate academic criteria for promotion.
A pioneering exception to the historic indifference to medical teaching was the prescient formation of the Shapiro Institute for Education and Research at Harvard Medical School (HMS) and Beth Israel Deaconess Medical Center (BIDMC). As described by the founders:
In an effort to organize a teaching hospital and a medical school in a manner that would position them to maintain more effectively their common academic mission front and center with the clinical business, HMS and the Beth Israel Hospital (BIH) created a joint venture in 1996. The new nonprofit Institute for Education and Research has education and research as its top (and only) mission. It is designed to provide additional and specific academic leadership and to enable the joint venture to undertake strategic planning for the academic mission.1
In 1996, the BIH merged with New England Deaconess Hospital to form BIDMC. Mount Auburn Hospital (MAH), another HMS teaching hospital, joined BIDMC under the umbrella of a new health care entity, CareGroup. The new educational venture was thus named The HMS-Beth Israel Deaconess-Mount Auburn Institute for Education and Research. In 1996, after a generous gift from the Carl J. and Ruth G. Shapiro Foundation, the name was changed to The Carl J. Shapiro Institute for Education and Research at HMS and Beth Israel Deaconess Medical Center, or the Institute.*
One of the Institute’s central commitments is faculty development. This encompasses advocacy for academic promotion within the clinician–teacher ranks, examination of the challenges of contemporary medical education, development of clinical teaching skills, and the establishment and administration of the Rabkin Fellowship in Medical Education. The Institute’s commitment to faculty development is based on the idea that the skills of the clinician–educator can be systematically and explicitly learned without solely relying upon the on-the-job approach of the past.
The Fellowships in Medical Education within the Harvard Medical System
The Rabkin Fellowship in Medical Education was established in 1998 in honor of Mitchell T. Rabkin, MD, CEO emeritus of the BIH. The Rabkin Fellowship provides faculty an opportunity to develop the expertise and skills needed to launch or advance academic careers in medical education and/or academic administration. The Rabkin Fellowship is open to faculty based at all Harvard-affiliated institutions and is designed to prepare future leaders in medical education. They form a “learning and teaching community” committed to supporting themselves and other colleagues in achieving the goal of better teaching.
The Mount Auburn Fellowship in Medical Education was established in 1999 and follows the same curricular structure as the Rabkin Fellowship. In 2004, a modified version of the Mount Auburn Fellowship was initiated for fellows of the Academy at HMS.
The goals of the fellowship programs are to
* help faculty develop and enhance their skills as educators;
* provide faculty an opportunity to conduct scholarly research or an educational project in an area of interest and importance in medical education;
* support the fellows as educational leaders and change agents within the AHC; and
* create a community of educators who continuously strive to improve the field of medical education.
The initial funding of the fellowship came from philanthropic support and from the founding institutions (BIDMC and HMS), with subsequent underwriting from MAH. Rabkin fellows chosen from the BIDMC and MAH receive an annual stipend of $25,000 plus fringes, allocated to their departments from Institute funds. Fellows chosen from other Harvard-affiliated hospitals are supported for their fellowship time by their parent institution. The Rabkin Fellowship in Medical Education is budgeted within the Shapiro Institute for Education. The Mount Auburn Fellowship in Medical Education is sponsored by the Department of Medical Education at MAH. MAH faculty employed by the hospital use time allocated contractually for medical education endeavors to participate in the MAH fellowships. The Academy fellowships are under the auspices of the Academy at HMS and are supported by the Morgan-Zinsser and Curtis Prout Academy fellowship funds at the annual level of $25,000 for each fellow.
As of June 2006, the three fellowships in medical education have graduated 63 physicians. The fellows represent a variety of clinical disciplines including anesthesiology, medicine, neurology, obstetrics–gynecology, pediatrics, radiology, emergency medicine, and surgery. At their inception in 1998 the fellowships focused on the clinical faculty, primarily because of the relative paucity of organized, ongoing programs available to address their particular learning needs and professional development. The fellowships, however, have always been open to all faculty who teach in both the preclinical and clinical years, as well as in graduate and continuing medical education.
Some fellows have participated in the program during the early stages of their careers, whereas others have had over 10 years of teaching experience. Class sizes have ranged from two to eight. It is our view that the ideal number for interactive seminars and effective group development is six. In 2006–07, six fellows are enrolled in the BIDMC program, six in the MAH program, and five at the Academy.
The fellows are chosen through a competitive process, which begins with a request for applications. Candidates are required to submit
* a personal statement outlining the applicant’s interest in teaching and/or academic leadership, and defining personal and/or professional goals in pursuing this year-long course of study;
* a question or project to be undertaken during the fellowship;
* a letter of support from the department or division chief;
* a current curriculum vitae (CV); and
* letters of reference.
Applicants are interviewed and selected by a committee of faculty who are responsible for the fellowship.
The medical education fellows are required to undertake an analytic study, an educational project, or research focusing on an important issue in medical education. Fellows each select a mentor in addition to the fellowship faculty to help guide their project’s development. The fellows also provide additional support and peer review for each others’ projects over the course of the year. Finally, the fellows summarize their projects in written reports and formal presentations at a concluding symposium.
The fellowship is structured to occupy and compensate 20% of a fellow’s time. The fellows spend time preparing for and attending the weekly seminars and conducting the required project. This arrangement permits the fellows to continue with their usual responsibilities, only modifying their schedules for this supported time. The advantage of this structure allows continuance of the fellows’ departmental salaries while they begin to implement the educational strategies learned in the fellowships.
The fellowship seminars are conducted at three sites: the Center for Education at BIDMC, the MAH, and HMS. We (the authors) lead these sessions and serve as teachers and mentors for the medical education fellows. Invited experts co-lead selected seminar sessions. Staff support is provided by each of the fellowship sites, as are the required resources for financial support of the fellows and provision of needed materials for the programs.
The fellows at the BIDMC and MAH meet weekly for 10 months (September through June) at separate sites for two-hour seminars during the academic year. The program at HMS meets monthly for two-hour seminars also for 10 months of the academic year. The medical education curriculum was added to the existing Academy fellowships at HMS in 2004–05. Previously the Academy fellowships were designed to support junior faculty projects, but did not have a component dedicated to ongoing seminars in medical education. In 2004–05 the fellowship directors began to meet monthly with the HMS Academy fellows using core elements of the Rabkin and Mount Auburn Fellowship curricula.
Fellows from all three programs come together for a number of seminars. A majority of these are dedicated to medical education research principles taught by local and national experts. In addition, past and present fellows convene twice a year to reflect and discuss challenging issues in medical education. The past fellows also serve as project consultants for the current fellows.
The fellowship curriculum covers a broad spectrum of historical and contemporary issues in medical education. Some of these topics include
* the historic evolution and financing of medical education;
* the skills needed for curriculum development, design, and evaluation;
* the application of adult learning theories to the clinical setting;
* the enhancement of teaching skills needed at the bedside, ambulatory, operating room, and classroom arenas, including exercises in peer review, lecturing, and small-group and case-based discussion;
* the skills needed for educational administration and leadership;
* the relevance of the humanities to medical education;
* research in medical education;
* writing for publication;
* sources of educational funding;
* the role of technology/simulation in medical education; and
* the skills of self-reflection and self-renewal.
Experiential learning is a key component of the fellowship. Fellows conduct and report on master clinician–teacher observations, are videotaped and given feedback on lecturing techniques, engage in role plays providing difficult feedback to learners, lead case-based discussions, conduct peer reviews, and submit written reports of memorable teaching and learning experiences. Fellowship graduation requirements are satisfied by seminar preparation and attendance, as well as the completion of the fellow’s project.
We strive to create a respectful “learning and teaching community” committed to the goals of better teaching. The fellowship provides a safe environment in which the fellows give and receive feedback and support as they develop the knowledge, skills, and attitudes needed to implement organizational and educational change.
Other educational faculty development opportunities within HMS and its affiliated hospitals exist, but are predominately individual lectures, workshops, three-week courses, and mentoring. The Rabkin, Mount Auburn, and Academy fellowships, however, are the only stand-alone offerings designed solely for HMS faculty that meet regularly for the entire academic year and involve extensive readings, planned curricular activities, and completion of a required educational project.
The fellowship directors meet after each session to debrief and plan upcoming seminars with particular attention to identifying connecting concepts between the sessions and designing teaching plans that meet the needs of the fellows. In addition to soliciting ongoing feedback from the fellows about the curriculum, two sessions during the year are devoted to eliciting in-depth reflections about the program and its impact on the fellows’ personal and professional development. Regularly scheduled meetings with each fellow throughout the year afford additional opportunities to garner feedback on the fellowship experience, provide time for further reflection, and allow for in-depth discussion of the fellow’s project. These meetings are also natural opportunities to provide support and counsel to the fellow regarding the challenges of being a change agent in an academic environment.
In 2004, the program directors began an ongoing evaluative study of the fellowship in medical education. The goal of the study is to examine the outcomes of the fellowship, including its personal and professional impact, using both qualitative and quantitative methods. The research team is applying qualitative analytic techniques to the examination of personal statements about teaching written before and at the end of the fellowship. A trained research assistant has conducted individual, semistructured interviews with all previous graduates of the program. These have been recorded, transcribed, and qualitatively analyzed for major themes. The team has also designed a template to use for the quantitative analysis of pre- and post-fellowship CVs, the results of which will help to characterize the professional impact of the fellowship year. The results of the study will be presented in separate reports for publication. The fellowship directors will incorporate the lessons gleaned from the data to continuously improve the quality of the program. In addition to demonstrating the efficacy of the fellowship, the fellows’ reflective statements, interviews, and CV preparation help the fellows document specific outcomes and stimulate reflection regarding their educational activities and personal development. They can then choose to use this documentation and reflection to improve the quality of their educational endeavors and to achieve academic promotion.
After the Fellowship
The fellows have assumed significant institutional educational roles after the completion of fellowship training, which we feel is due in part to that training. These leadership positions have ranged from course, clerkship, and faculty development directorships to the vice presidency for medical education at the BIDMC. Graduates of the fellowship often serve on major local and national educational committees. Similarly, fellowship projects ranging from innovative curricula to new teaching models have become part of departmental and institutional practice.
The fellowships in medical education require ongoing funding for infrastructure, administrative personnel, resources, and fellows’ salary support. Evaluation and evidence-based demonstration of the impact and outcomes of the fellowship are essential to gain the acknowledgment of the importance of the role of teachers and faculty development. Implementation of practical, ongoing evaluative efforts and the securing of continued funding remain central challenges to the continuance of the fellowships.
Having established a feasible and well-accepted fellowship in medical education program at three sites within the Harvard medical system, we now see our challenge as expanding these initiatives to larger segments of the Harvard medical faculty. Central elements of the fellowship curriculum have already been presented to core teaching resource faculty from multiple departments as part of important educational initiatives at BIDMC and MAH. A full-day symposium in medical education has also been presented to key teaching faculty from HMS at large, and was also attended by the current fellows. Lastly, HMS is implementing a major curricular change and has established The Academy Center for Teaching and Learning committed to enhancing the teaching skills of the entire faculty. Our fellowship experience will contribute to the resources in place and facilitate the development of teaching skills within this center, benefiting physicians, trainees, and ultimately patients who receive their care from the HMS-affiliated institutions.