The VPE is a member of the medical center’s Operations Council and Medical Executive Committee. In this role, the VPE advocates for educational programs and ensures that decisions regarding clinical, budgetary, and space issues are made with appropriate consideration for the needs of the training programs. Furthermore, as a member of these key administrative branches, the VPE is able to ensure that the annual operating plan of the Center for Education supports the goals and objectives of the medical center, a critical requirement for sustaining financial support in the present fiscal climate. In addition, we charged the VPE to work with each clinical chief to develop departmental models for teaching and plans for allocation of GME funds in concert with those models. The departmental and division chiefs fully implemented these models in academic year 2007 and are making the results available to faculty to ensure they are aware of, and understand the uses of, educational funds. With a dual administrative role at the medical school and medical center, the VPE is able to coordinate in a meaningful way UME and GME programs.
As a member of the Academy at HMS (a formal society of HMS scholars chosen by competitive selection), the VPE has created the first “branch” of the Academy at a Harvard teaching hospital. Resource faculty members (see below) are appointed associate members of the Academy at HMS and the first members of the BIDMC Academy.
In highlighting several of the many programs created under the Strategic Plan for Education, we have focused on those that benefited from centralized oversight for education, thereby enabling successful interdepartmental collaboration, fortification of the UME–GME continuum, and increased support for faculty development. In addition, these programs explicitly address the need identified by all constituents to increase time dedicated to teaching.
To address the need for improved faculty development, we adopted a “core faculty” model to bring faculty development to the clinical departments. We modeled the resource faculty development program after our Rabkin Fellowship in Medical Education10 in that we provided a curriculum in educational theory, discussed sentinel articles and research in medical education, and gave them opportunities to practice teaching skills with peer feedback. Resource faculty serve as liaisons from the Center for Education to individual departments to enhance professional development activities throughout the medical center. Stipends from BIDMC, HMS, and the Shapiro Institute support resource faculty whose nomination by department chairs additionally ensures that they are provided with dedicated time for teaching and professional development. These faculty participate in monthly sessions to improve their own skills as teachers, develop department-specific curricular materials, serve as peer reviewers for other teachers in the medical center (via a formal teaching consultation service started in March 2006), and assist faculty in their departments with academic promotion along the clinician–educator track.
Principal Clinical Experience.
To address the need to improve medical student teaching, we designed a longitudinal program for third-year medical students that serves as one of the experimental pilots for the ongoing curricular reform effort at HMS.11 In the Principal Clinical Experience (PCE), students spend their entire academic year at BIDMC rotating through traditional core clerkships along with non-PCE students. Basing these students at a single site with a core faculty member responsible for their total development for the year allows us to address challenges in clinical training such as fragmentation of faculty relationships, lack of longitudinal assessment, poor tracking of developmental needs, and insufficient time for learning. Students participate in an intensive, weeklong transition course at BIDMC before beginning their clerkships. The program also provides a longitudinal curriculum that includes, among other elements, (1) case conferences that encompass discussion of humanistic as well as clinical issues, (2) yearlong ambulatory care preceptorships, (3) an interdisciplinary, longitudinal curriculum that integrates basic and clinical sciences in a tutorial format, (4) computer-based and mannequin-based simulation exercises, and (5) structured assignments in case-based and reflective writing.
Simulation and Skills Center.
To enhance residency and medical student education and to address authentic skills assessment, we established a medical simulation center that is codirected by an anesthesiologist and a surgeon and that serves as a resource for all departments within the medical center. The simulation center integrates multiple types of medical simulation into interdisciplinary curricula designed to teach and assess management in acute emergencies, team-based interactions, and procedural skills. Our expectation is that the simulation center will improve quality of care, reduce medical errors, and enhance working relationships among physicians, nurses, and clinical staff, thereby serving as a concrete example of the ways in which the educational mission can support the clinical mission of the medical center, through, for instance, programs on central line placement and team training for acute crisis management. The simulation program is firmly entrenched within the Center for Education, which provides support for curriculum development and assessment. This organizational structure was a key element in the center’s designation as a Level I American College of Surgeons accredited educational institute.12
We have established an annual event that commemorates medical education at the hospital, entitled “Education Week: A Celebration of Education at BIDMC.” In June 2006, programs included education grand rounds, the official opening of the Simulation and Skills Center, resident research day (poster and oral presentations of selected abstracts from residents and fellows), a symposium celebrating our fellowship in medical education (a reunion of Rabkin fellows and talks from featured alumni), and a teaching award ceremony held in a large public space to ensure the greatest visibility for the entire BIDMC community. In 2007, in addition to the activities outlined above, we instituted a visiting professorship in medical education. The visiting professor spent several days at BIDMC and HMS, spoke at education grand rounds, met with faculty and medical education fellows to discuss ongoing projects, and counseled individuals and departments interested in education.
Web-based modules for the Accreditation Council for Graduate Medical Education competencies.
To improve resident education in the Accreditation Council for Graduate Medical Education (ACGME) competencies, we commissioned faculty to develop Web-based modules on systems-based practice and practice-based learning and improvement. The faculty designed these modules for use by residents across departments, and the modules allow us to document compliance with the ACGME mandates.
Office of Educational Technology.
In 2004, the Center for Education created an Office of Educational Technology, extending the institute’s pioneering work on virtual patients.13 The office is responsible for the development and implementation of Web-based educational resources for the Shapiro Institute and provides consultative services for faculty interested in multimedia programs.
Office of Educational Research.
In July 2006, the Center for Education created an Office of Education Research to aid and augment the center’s educational research activities. Two individuals (1.25 FTE) with doctoral training in cognitive psychology and sociology staff this office. In addition, they have also assisted other faculty in study design, IRB issues, grant writing, and statistical analysis. In its first 12 months, the office assisted in the submission of six education grants.
Scholarly activities emanating from the Center for Education include 29 presentations to national or international audiences, 26 abstracts and posters, 13 published articles, three book chapters, and a textbook. These activities highlighted research from the Center for Professional Development, the Office of Educational Research, the Office of Educational Technology, the Office of GME, and the Simulation and Skills Center.
The focus of the work featured BIDMC programs such as the PCE and the Web-based ACGME modules, and the work of the resource faculty through the Center for Education. Coauthorship by individuals in many different offices and centers within the Center for Education demonstrates the ease of collaboration that the organizational structure has provided.
Finances and resources.
The consolidation of administrative and support structures for the education mission has enabled us to achieve significant efficiencies compared with the preexisting model in which each department had to provide these services for its own faculty. These efficiencies have also enabled us to provide new programs (Office of Educational Research, Office of Educational Technology, resource faculty, the Simulation and Skills Center) while both strengthening preexisting professional development initiatives and facilitating greater collaboration within several components of the Center for Education. For example, the Office of Educational Research supports not only the GME office and program directors in the development of assessment tools, but also the Office of Professional Development in the teaching of critical thinking skills. Additionally, the Office of Educational Technology equips programs across the Center for Education with technical development support, such as computer-based simulation in the Simulation and Skills Center, Web-based resources for the PCE students, and GME administrative applications. Funding for these programs has come from three sources: philanthropy, HMS, and BIDMC. In particular, the hospital’s support of the Center for Education originates from the annual operating budget. The success we have had in the three years (2005, 2006, 2007) since completion of the strategic review has encouraged a major new seven-figure pledge from a donor to partially support the program expenses for the next 10 years. The link of educational programs to elements of the medical center’s annual operating plan, particularly with respect to patient safety initiatives, has strengthened our ability to justify using operation revenues from the medical center’s budget. For example, a simulation training program for residents that is focused on central venous catheter placement aims to reduce complications, and our clinical triggers (formalized rapid response to clinically deteriorating patients) program for resident trainees has reduced unanticipated cardiac arrests.14–15 As our Office of Educational Research has grown, we have secured grants to support some of our programming, and we are developing additional grant applications. This year, we will offer two continuing medical education courses for which attendees will pay tuition. Our 2007 fiscal year operating expenses, including all programs noted above, were approximately $1.9 million. We believe the structure and programs we have created will provide us with the best opportunities to define and achieve outcomes that all constituents will perceive as educationally meaningful and that department chairs, the medical school dean, and the medical center leadership will understand as adding value to our collective enterprise.
Barriers to implementation
The process we followed during the strategic review enabled us to build a consensus among critical members of the medical center community. The unanimous vote of the BIDMC board of directors in support of the recommendations emanating from the review provided validation of BIDMC’s commitment to the educational mission. Nevertheless, some still resisted the implementation of those recommendations.
Creation of a central administrative structure for education and the proposal to create greater accountability for, and transparency in, the allocation of teaching funds threatened the autonomy of the department chairs. Similarly, some parties viewed with skepticism and, on occasion, disdain the efforts to bring together previously independent clerkship directors and to require more explicit outcome measures for both the undergraduate and graduate medical education programs. Underlying much of the early opposition were two major concerns: loss of prerogatives, and a fear that reallocations to other programs would compromise resources. Over time, we addressed these concerns by showing that our analyses, proposals, and programs would ultimately provide greater support to faculty and directors, generate new resources (both financial and personnel), rationalize a reward system previously viewed as arbitrary, and enhance the visibility and value of the educational efforts of all faculty. One example of how faculty members reap the benefits of the strategic plan implementation is that the VPE must approve the departmental models for financing teaching activities. This process has focused the attention of the department chairs, in many cases, on the explicit manner in which teaching is provided and on the faculty who provide the teaching. Additionally, the resource faculty have flourished as a group, providing support, guidance, and insights for each other’s projects. We are beginning to see interdepartmental collaborations as well. For example, members of the departments of orthopedics and general surgery are beginning work on the assessment of intraoperative teaching, and the resource faculty from general surgery and psychiatry have held joint rounds with surgical residents. Personal meetings between the VPE and the more recalcitrant members of the BIDMC community to hear concerns, answer questions, dispel rumors, and make clear that there were no hidden agendas were particularly useful. The VPE met frequently with the department chairs throughout the implementation phases of the plan to ensure a sense of collaboration and to demonstrate the benefits to their department of the programs offered. As resource faculty, in particular, flourished in their new roles, the initial doubts and fears of department leaders diminished. In hindsight, we would have included an early institution-wide evaluation of GME programs, given the prominence of these programs in the recommendations of the strategic review, but we are tackling this initiative currently.
Our efforts to build interdepartmental programs and, via our resource faculty initiative, to gain allies within each department, enabled us to build support from many sources, employing clinical colleagues who were often the greatest doubters. Throughout the implementation phase, we never lost sight of the goal of adding value to the lives and work of our educators, our departments, and the medical center.
The realignment of our educational mission would be incomplete without a systematic evaluation of our efforts. We are embarking on a hospital-wide survey of our faculty about their perceptions of the new financing schemes for medical education. We continue to maintain a database that tracks the scholarly activities of faculty affiliates of the Center for Education to document the growth of scholarship since the implementation of our plan. As mentioned above, we are conducting an extensive evaluation of our GME programs using metrics explicitly aligned with the clinical mission in patient satisfaction and safety. With respect to links between education and the research missions, the strengthening of the educational program offered by the medical center helps attract top trainees, some of whom ultimately take positions in the laboratories of our faculty. In addition, during the development of a recently submitted Harvard Clinical and Translational Science Award application, the applicants consulted the VPE about the educational component of the grant; we anticipate a greater role for the Center for Education in the preparation of researchers in the future. Lastly, we are an integral part of hospital strategic planning and implementation; in addition to the VPE’s involvement in core administrative decisions, our hospital’s goals serve as the guidepost in determining the ultimate impact of our center’s programs and research, and the newly initiated medical center capital campaign will prominently feature our educational programs and needs.
Academic medical centers are assuming an increasing proportion of the burden of educating trainees as demands on clinical faculty to teach clinical correlations in the basic sciences grow and as the requirements and expectations placed on clinical training become more rigorous. Institutional and program requirements for graduate medical education are expanding at similarly fast rates. We have provided an example of how a formal, institution-wide review of the educational mission can focus goals and generate support for a reevaluation of the academic medical center’s role in producing future generations of physicians. Ultimately, the recommendations arising from the review and the programs implemented addressed the four essential elements of an organizational structure for education, as outlined by Fincher et al: an explicit administrative structure, human resources, political issues, and symbolic concerns.8 Although the specific details of such an analysis and the outcomes resulting from it must vary from one institution to another according to the particulars of the culture, politics, faculty, and resources of the local environment, there is much to be gained from the effort—the hills to climb seem less steep, the burden less heavy, and the challenges confronting medical education more manageable.
The authors gratefully acknowledge Carol Hughes of the Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center for critical administrative support of the processes outlined in this document from beginning to end.
Catherine DesRoches, PhD, of the Harvard School of Public Health, and Cogent Research were compensated as consultants for methodological design of the self-study, data collection, and data analysis.
Dr. Michael Whitcomb was a consultant on this project. He reviewed self-assessment survey materials and helped conduct focus groups of constituents at Beth Israel Deaconess Medical Center. He was not involved with the final decision to publish this article.
1 Ludmerer K. Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999.
2 Kirch DG, Grigsby RK, Zolko WW, et al. Reinventing the academic health center. Acad Med. 2005;80:980–989.
3 Saxton JF, Blake DA, Fox JT, Johns MM. The evolving academic health center: Strategies and priorities at Emory University. JAMA. 2000;283:2434–2436.
4 Weiner BJ, Culbertson R, Jones RF, Dickler R. Organizational models for medical school–Clinical enterprise relationships. Acad Med. 2001;76:113–124.
5 Griner PF, Danoff D. Sustaining change in medical education. JAMA. 2000;283:2429–2431.
6 Pardes H. The perilous state of academic medicine. JAMA. 2000;283:2427–2429.
8 Fincher RE, Simpson DE, Mennin SP, et al. Scholarship in teaching: An imperative for the 21st century. Acad Med. 2000;75:887–894.
9 Rosenblatt M, Rabkin MT, Tosteson DC. How one teaching hospital system and one medical school are jointly affirming their academic mission. Acad Med. 1997;72:483–488.
10 Hatem CJ, Lown BA, Newman LR. The academic health center coming of age: Helping faculty become better teachers and agents of change. Acad Med. 2006;81:941–944.
11 Bell SK, Krupat E, Fazio SB, Roberts DH, Schwartzstein RM. Longitudinal pedagogy: A successful response to the fragmentation of the third-year medical student clerkship experience. Acad Med. 2008;83:467–475.
13 McGee JB, Neill J, Goldman L, Casey E. Using multimedia virtual patients to enhance the clinical curriculum for medical students. Medinfo. 1998;9:732–735.
14 Howell MD, Folcarelli P, Moorman D, Yang J, Mottley L, Aronson M. Can an intern run a rapid response team? Abstract presented at: 36th Annual Critical Care Congress, Society of Critical Care Medicine; February 2007; Orlando, Fla.
15 Howell MD, Zullo N, Folcarelli P, et al. Monitoring and adjusting a rapid response team implementation using a novel informatics tool. Abstract presented at: 24th International Conference on Quality in Health Care (ISQuA); September 30 to October 3, 2007; Boston, Mass.
© 2008 Association of American Medical Colleges
This article has been cited