Riesenberg, Lee Ann PhD, RN; Little, Brian W. MD, PhD; Wright, Vaughn EdD
Most physician educators have received little training for their teaching roles. Time constraints and the demands of practice make it even more difficult to acquire this knowledge. Physicians are plagued by increasing accountability and documentation requirements as well as exponential growth of the volume of medical knowledge and treatment options. Other pressures include rising patient expectations, diminished prestige, loss of autonomy, and demands to decrease costs and increase revenue. Furthermore, today’s medical practitioner must deal with various health plans with dissimilar practice guidelines, data systems, profiling practices, and reporting requirements.
Given these factors, it may be impossible to add thorough understanding of adult education theory, valid needs assessment, writing objectives, curriculum development, competency-based education, evaluation, and medical education research to the learning portfolio of the physician educator. Faux estimated that it would take 75 minutes per working day for a physician to stay current with the medical education literature, which is not practical given current demands.1
In recent years, numerous reports on medical education in the United States have called for major reforms.2 In 1996, the Institute of Medicine launched the Quality of Health Care in America project. In the third and final report created by this initiative, the authors state that “education for the health professions is in need of a major overhaul.”3(p1) New medical schools are opening, and existing schools are increasing enrollment in response to projected physician workforce shortfalls. Physician faculty facing all of these increased demands have little time to teach and assess learners and even less time to work on curricular improvement and related activities.
One solution is to use professional nonphysician medical educators. Here, we define the nonphysician medical educator as an individual who specializes in medical education and has (1) either a master’s or doctorate degree in education or a related field, or (2) a clinical educational background (e.g., nurse, nurse practitioner, clinical nurse specialist, physician assistant) and added training or experience in education. Our focus in this article is on nonphysician professionals with education expertise in aspects of the clinical education of medical students, residents, and fellows, or, to a lesser extent, the continuing medical education of physicians.
Nonphysician medical educators can offer added value through their alternative perspectives on problems in medical education. They have unique training (e.g., adult learning theory, educational research skills, instructional design) and can provide clinical skills training and evaluation at a reduced cost. The well-known essential characteristics of effective clinical teachers—enthusiasm, clarity, organizational skills, and adeptness in interacting with medical students and residents4—are all characteristics that nonphysician medical educators can easily master. Our purpose in the study reported below was threefold: (1) to conduct a historical content analysis and literature review of the early development of nonphysician medical educators in the United States, (2) to conduct a thorough review of the English-language literature on health care professionals working as nonphysician medical educators, and (3) to develop a job description resource for the nonphysician medical educator working in the clinical setting.
Historical development of the nonphysician medical educator role
For the review of the development of the nonphysician medical educator role, in 2007 we combined a historical content analysis of resources with literature searches in Medline and CINAHL databases. We used historical resources familiar to us that are relevant to the development of the nonphysician medical educator role. At the same time, we conducted multiple literature searches, spanning the literature from 1950 to the first week of December 2007. We also included English-language articles published from the 1920s to December 2007 and other resources with historical content relevant to the review. The reference sections of all relevant articles were searched for additional articles.
Health care professionals working as medical educators
To investigate the published literature on nonphysician health care professionals working as medical educators, in 2007 we searched Medline and CINHAL databases from 1950 to the first week of December 2007 for English-language articles. Articles were excluded if they focused on standardized patient programs, medical school basic science courses or elective courses, or single lectures (medical school or residency) with interdisciplinary faculty members. The reference sections of all relevant articles were searched for additional articles.
Job descriptions of nonphysician medical educators
In an attempt to develop a job description resource for those interested in hiring nonphysician medical educators, we designed an archival study of publicly available job descriptions of nonphysician medical educators.
The sources of job descriptions were association job boards (Association of American Medical Colleges [AAMC], Association for Hospital Medical Education, Accreditation Council for Graduate Medical Education [ACGME], Alliance of Independent Academic Medical Centers, and Society of Directors of Research in Medical Education) and medical education listservs (DR-ED, MED-ED, CGEA, NEGEA, SGEA, STFM). Data collection occurred between July 1, 2006 and November 30, 2007.
We reviewed job descriptions requiring a bachelor’s degree, with a master’s preferred; a master’s; or a doctorate-prepared nonphysician medical educator for required duties, which included roles, responsibilities, and specific duties related to the educational aspects of medical education. We abstracted and rewrote these in phrase format, each phrase beginning with a verb. Similar phrases were combined to create one phrase that incorporated all components identified. In addition, when the abstracted data seemed unclear regarding the actual required duty, we used our knowledge of medical education to elaborate.
Historical development of the nonphysician medical educator role
Our historical content analysis of resources known to us yielded five resources (four Web resources and one association commemorative book), and our literature searches yielded 425 potentially relevant articles. Thirteen articles, one association commemorative book, and four Web resources met our inclusion criteria of describing aspects of the early historical development of the nonphysician medical educator role.
The U.S. nonphysician medical educator profession may have had its beginnings in the 1920s at the University of Minnesota. There was a brief collaboration between the faculty of the school of medicine and the faculty of the education department, which resulted in two publications focused on improving medical education quality and the use of nonphysician medical educators,5,6 but not much more.7
At the same time, medical education associations began to focus on the process of clinical education. At the American Medical Association–sponsored annual meeting (first held in Chicago at the Palmer House), hospital-based medical educators discussed issues of common interest (Marvin Dunn, MD, deceased, personal communication, 2004). In the early 1950s, this group began meeting separately and formed the organization that became the Association for Hospital Medical Education in 1956.8 Several years later (1969), the AAMC created the Group on Educational Affairs, which has evolved to have sections on undergraduate, graduate, and continuing medical education, as well as research in medical education. A major focus of all of these groups has been the study and improvement of the quality of medical education.
In the 1950s, Hilliard (“Hill”) Jason, MD, obtained a doctorate (EdD) from the University of Buffalo (now the State University of New York at Buffalo).7 Dr. Jason was the first known physician to pursue added qualifications in education.7 He and his wife, Jane Westberg, PhD, have devoted their careers to developing and disseminating health professions educational materials designed to improve teaching.
In 1955, a sustained dialogue started between George Miller, MD—an internist and one of the earliest physicians to promote the process of education in medical education as a field of study—and Robert Fisk, PhD, the dean of the School of Education at the University of Buffalo.7 This partnership resulted in an annual summer seminar designed to improve medical education teaching quality.7 One of the unique aspects of those courses was that they were cotaught by a physician and a nonphysician professional educator.7 As a result of this collaboration and the success of the summer seminars, the first professional educators were hired to work full-time in the medical school.7 Since then, the experiment has grown exponentially across the United States.
In late 1958 and 1959, the first three offices of research in medical education opened at U.S. medical schools: Case Western Reserve, the University of Illinois at Chicago, and the Medical College of Virginia.9 The directors of the first two were physicians (T. Hale Hamm, MD and George Miller, MD); Edwin F. Rosinski, EdD, the director at the Medical College of Virginia, is thought to be the first nonphysician medical educator to be called an educationist.10 Later, those three directors were appointed by the AAMC to organize and conduct the first Research in Medical Education (RIME) conference, held in conjunction with the AAMC’s annual meeting in 1962. From their initial efforts, the RIME conference has grown to be a staple in medical education. By 2001 there were 61 medical schools in North America with offices of medical education,11 and today offices, units, or departments of medical education are ubiquitous at medical schools.12
In 1963, Howard Barrows, MD, a neurologist and medical educator at the University of Southern California, began using what he called programmed patients to teach third-year medical students.13,14 From the first article published on programmed patients in 1964,15 the use of what are now called standardized patients (sometimes simulated patients) for teaching and evaluation has grown exponentially. Currently, standardized patients are an integral part of medical education. The use of standardized patients has led to the creation of the Association of Standardized Patient Educators, an international organization established in 2001,16 as well as a tremendous growth in the need for nonphysician medical educators to direct and manage standardized patient programs.9,13
An oral history project carried out by investigators at several medical schools7 resulted in articles17–22 written about six exemplars, individuals hired as professional educators who made significant contributions to medical education. The series brought formal recognition to the nonphysician medical educator as well as to the importance of the study of medical education. It also marked a milestone. From the brief unsustained dialogue between the faculty of the medical school and education department at the University of Minnesota in 1920 to peer-reviewed publications documenting the contribution of professional educators to medical education, the recognition of the importance of professional nonphysician medical educators has grown dramatically.
Family medicine and nonphysician medical educators.
Since the establishment of the specialty of family medicine in 1967, nonphysician medical educators have been an integral part of their faculty.23 At the outset, these nonphysicians were behavioral scientists (psychologists and social workers).24 According to Magill,24 by 1988 one in five family medicine faculty members was a nonphysician. By 1991, this number had increased to almost one in four.23 Of greater interest, perhaps, is the fact that in addition to psychologists and social workers, the nonphysician faculty now included members with degrees in education, sociology, theology, administration, and pharmacology.23
Significant changes in the accreditation processes in graduate medical education (GME) have increased the need for nonphysician professional medical educators. In 1992, the ACGME adopted the first formal institutional requirements, which were initially just a few pages long. Fifteen years later, the ACGME Institutional Requirements are 16 pages long and the Common Program Requirements are 15 pages long. In a similar move, the American Osteopathic Association (AOA) established the Osteopathic Postdoctoral Training Institutions in 1995, which brought more structure and a system to accredit osteopathic graduate medical education programs. The result is rapidly increasing accreditation requirements from both GME accrediting associations. Similar changes with increased regulation and requirements have occurred in the medical school environment. These advancements have increased demand for valid learning experiences at a time of decreasing resources for medical education and increasing clinical demands on physicians.
Duty hours restrictions went into effect in 2003. For most institutions, this meant revising rotation schedules, instituting night float systems, or creating other methods of coverage; it also meant developing duty hours monitoring systems. Each of these changes brought with it new responsibilities at a time when physicians were feeling pressure from every direction.
The paradigm shift from assessing process to outcomes, made first by the ACGME and subsequently endorsed by the AOA, has led to radical changes in medical education. The year 2006 marked the beginning of phase three of the ACGME general competencies. In addition to defining competencies required for each rotation, revising curriculum to include the competencies, and instituting competency-based evaluation tools, GME programs must now use outcomes data to inform program improvements.
Successfully making the paradigm shift and fully embracing the general competencies requires new skills in evaluation, curriculum design, and outcomes research and has added another layer of work that must be accomplished. We believe that nonphysician medical educators are ideally suited to oversee and manage these new activities.
Health care professionals working as medical educators
Our literature search yielded 95 potential articles (57 from search and 38 from reference sections); 39 met our inclusion criteria.
The first published reports of nurses teaching and evaluating medical students and residents appeared in the 1970s. Nurses were employed by Southern Illinois University (SIU) in Springfield to teach and supervise the daily activities of medical students on rotation in 1974.25 At SIU, “The advantages of having a nurse work on a daily basis with students were obvious immediately.”25(p868)
Numerous reports since that time have documented nurses’ ability to teach patient education to residents26 and clinical skills to medical students.27–30 Analysis of medical student and faculty attitudes have supported “the involvement of nonphysician health professionals in teaching medical students.”31 Similar results have been obtained in the United Kingdom, where medical students strongly supported nurse tutors who taught them clinical skills.32 In addition, nurses do not have to be on the faculty to provide valuable instruction. Bonner33 noted that an important aspect of the expert nephrology nurse’s job was teaching medical students, residents, and physicians about hemodialysis.
Further evidence of value added was found in a children’s hospital study. In 1993, the duPont Hospital for Children in Wilmington, Delaware implemented a nurse–medical student preceptor program. This experiment resulted in statistically significant increases in direct pediatric patient care for the medical students assigned to work an eight-hour shift with a nurse when compared with the frequency of such care by the control students, who did not work with a nurse.34 In addition, at least some nurses have obtained greater instructional expertise through their normal educational process. Howe and colleagues35 demonstrated a high level of teaching development among nurses involved in teaching medical students in primary care settings.
Evaluation is another area in which nurses can provide valuable contributions. A 1984 study conducted at the Maryland Institute for Emergency Services System concluded that nurses can be a successful component of the process of evaluating residents.36 Others have demonstrated that nurses and other nonphysician health care staff are willing to evaluate residents’ and faculty members’ humanistic behaviors and that they can achieve reliable and valid scores.37–40 Of equal importance, nurses can evaluate behaviors not often witnessed by physicians41; also, nurses’ evaluations can be used to improve humanistic characteristics in residents.42
Other health care professionals.
The first mention in the literature of nurse practitioners’ teaching medical students is almost four decades old as of this writing. For example, pediatric nurse associates (nurse practitioners) began teaching medical students physical diagnosis, interview techniques, health care maintenance, and growth and development, as well as providing guidance and feedback, during pediatrics clerkships in 1970 at the University of Arizona College of Medicine.43 The study’s authors demonstrated that medical students taught by the pediatric nurse associates performed statistically significantly higher on knowledge tests than did medical students in a control group.43 Also in the 1970s, the University of California, Davis, School of Medicine, Family Practice Department began using family nurse practitioners to teach medical students and residents. These nurse practitioners were well received and were considered to be excellent role models.44
At about the same time, the University of Pennsylvania successfully developed a nurse-practitioner-run pediatrics clinic, with the primary goal of educating “medical students, interns, residents, nursing students, graduate nurses, and nurse-practitioners.”45 Subsequently, the University of Arizona reported the use of nurse practitioners to teach first-year medical students physical exam skills and ensure that each student achieved mastery of skills.46,47 A study conducted at Johns Hopkins University School of Medicine showed strong support for pediatric nurse practitioners supervising medical students as they learned history-taking and physical exam skills.48 Schor48 compared medical students’ evaluations of pediatricians and pediatric nurse practitioners regarding their value as educators and found no differences. The medical students expressed strong approval of the pediatric nurse practitioners.
Nurse practitioners have been shown to be effective teachers of geriatrics,49 postpartum care,50 high-risk pregnancy,51 breast exams and breast cancer screening,52 ambulatory care,53 and home care services for dying and chronically ill patients who are homebound.54
An experiment that began with one nurse has grown tremendously. In 1992, Keck School of Medicine (KSOM) hired its first nurse educator for the surgery department.55 This first nurse educator was so successful that by 2006 KSOM had dedicated medical student educators (two physician assistants and eight advanced practice nurses) for every required clerkship. They assist clerkship directors by providing clinical teaching, learner remediation, evaluation of students and the program, monitoring clinical sites, making student assignments to sites, developing quizzes, and developing curriculum.55 Average medical students’ ratings for academic year 2005–2006 ranged from 4.00 to 4.85 on a 5-point Likert scale, with 5 being “strongly agree.”55 According to Elliott et al,55 15 medical schools in the United States and Canada had nurse instructors on surgery clerkships in 2006.
Others have described the successful use of a nonphysician health care education consultant in the Anesthesiology Department at Hahnemann University in Philadelphia.56 The nonphysician health care education consultant was found to be effective in residents’ and medical students’ curriculum development and in enhancing faculty members’ teaching skills. Physical therapists were successfully used to teach the musculoskeletal exam.57
Physician assistants and nurse midwives have joined the ranks. In one study, physician assistants proved to be valuable instructors of radiology residents.58 Another study demonstrated successful integration of physician assistants and nurse practitioners in their surgery service, with these health care providers becoming an integral part of the educational program.59 Finally, nurse–midwives have been used effectively to teach, supervise, and validate certain skill competencies in residents.60–62 According to Harman and colleagues63 (writing in 1998), just over half (54%) of all MD-granting medical schools in the United States were using nurse–midwives as instructors by 1994.
Growth of master’s and certificate-in-medical-education programs.
One manifestation of the increased need for nonphysician medical educators, as well as the demand for physicians with education training, is the rapid expansion of master’s degree programs and certificate in medical-and-health care-education programs. In a 1998 study, researchers identified 15 health professions higher education programs on three continents.64 Eleven programs offered master’s and five offered PhD’s, with five in the United States and three in Canada. In 2005, Cohen and colleagues identified 21 programs offering master’s degrees in medical or health sciences education in the English-speaking world, with six in the United States and three in Canada.65 Twelve of these offered certificate programs. In 2007, there were at least 40 such programs in the English-speaking world, with 11 in the United States and 4 in Canada (Riesenberg LA, Cohen R, Pratt D, Collins J, Urban M, Wright V, unpublished data, 2007).
Job descriptions of nonphysician medical educators
Our archival review yielded 132 nonphysician medical educator job descriptions. Through content analysis and combination of similar phrases, we created 237 distinctly different required duties in 17 categories (see Appendix 1 for these findings). We do not present these categories and job responsibilities as representing all possible nonphysician medical educator roles but, rather, as a sample of potential options. During the review period, the number of identified job descriptions increased, with 39 in the first nine months, 41 in the next six months, and 52 during the final two months of review.
By 2001, at least 20 major reports had been published since Flexner’s in 1910 that called for reform in medical education.66 The practice of medicine and medical education have become increasingly complex and demanding. As modern medical educators embrace the science of education, the need for multidisciplinary educators to fill roles that do not require a physician’s expertise continues to expand. In this way, the nonphysician medical educator can complement the unique knowledge, skills, and behaviors of the physician with the technical and theoretical foundation each educator possesses to make the learning process more rewarding for learners and more effective for institutions.
In addition, recent reports have stressed the importance of education and medical practice models that promote interdisciplinary teamwork.3,67 The nonphysician medical educator working side-by-side with physician faculty and leaders could provide an excellent role model of collaborative teamwork for medical students and residents.
There are limits to what the nonphysician medical educator can and should do. These are defined by the person’s prior education, training, and interests, as well as licensing and accreditation standards. A great deal has been written about the essential part physician role models play in the educational process of students and residents.68–70 Nonphysician medical educators’ contributions will never replace physicians’ instruction and guidance. Further, the nonphysician medical educator must develop a true partnership with the members of the educational team. The overall medical education environment can be a challenging one in which to flourish. The comparative lack of medical knowledge may artificially place the nonphysician educator in a second-class status. In addition, promoting change with new educational models—including nonphysician educators—may not be accepted. However, as medical education develops as a team activity, we believe the knowledgeable, credible nonphysician medical educator will gain acceptance and become a productive, cost-effective member of the health care educational team.
We have already seen the integration of the clinical pharmacist into the education of physicians during work rounds in high-intensity areas of the hospital, and we have also seen the involvement of librarians providing real-time, evidence-based literature searches for rounding residents. The nonphysician medical educator is emerging as another valuable member of the educational team.
We began our historical overview in the 1920s, when the first documented collaboration between education department faculty and medical school faculty occurred. Since then, the ranks of nonphysician medical educators have expanded to include a broad range of disciplines. Many professionals from diverse educational backgrounds have joined the medical education team. The full extent of their contributions, the diversity of their backgrounds, and the challenges they face have not yet been fully explored. Future studies should address these questions.
In our review of the literature on health care professionals working as nonphysician medical educators, we identified 39 articles published between 1961 and 2007. There was a gradual increase in the number of articles published per decade, with 1 in the 1960s, 7 in the 1970s, 7 in the 1980s, 12 in the 1990s, and 12 published between 2000 to 2007. It is safe to assume that the number will continue to increase.
Our review of the literature, our personal experience, and the increase in articles published over time lead us to conclude that nurses and other health care professionals are gaining acceptance as nonphysician medical educators. However, this is not an easy alliance. Physicians and other health care professionals have long been educated separately and worked in “silos.” Although the numbers of nonphysician medical educators may be growing, we recognize that they face challenges in these positions. Future studies should identify these challenges and seek ways to promote the success of these professionals. As the need to teach team training, promote interdisciplinary patient safety and quality improvement activities, and meet the evolving education, evaluation, accreditation, and regulatory needs of the 21st-century physician grow, so does the need to embrace the nonphysician medical educator.
Our study findings were limited by the extent of the published literature. There may be professionals who have dedicated their careers to medical education but whose contributions have not been documented. In addition, our review does not include the contributions of nonphysician medical educators to standardized patient programs, simulation education, medical school basic science courses or elective courses, or single lectures (medical school or residency) with interdisciplinary faculty members. Each of these could be a separate review and was beyond the scope of this study.
The presence of a professional nonphysician medical educator, able to help in the development of personal learning plans for continuing professional development, can provide added value as physicians work on expanding their educational portfolios. Further, as accreditation, credentialing, and maintenance of competency become more defined and complex, the knowledge, skills, and abilities of the nonphysician medical educator will help to ease these burdens for physicians.
Physician educators face many competing demands, which leave little time to focus on the many facets of medical education management, administration, and innovation. We propose that professional nonphysician medical educators offer a cost-effective way to meet many medical education needs, freeing physicians to provide high-quality education and supervision of the nation’s medical students and residents. We see this model expanding, both from the direct demand of the market and from the increasing number of formal education programs for medical educators. It remains to be seen whether this collaboration will achieve long-term success.
Numerous publications cited here have documented the value of nonphysician medical educators. We call now for outcome studies to further measure their effectiveness. Future studies should address economic efficiency and the effect on learners and evidence-based medical education using valid and reliable measures. We hope that nonphysician medical educators will be among those who seek to advance this research agenda.
Special thanks to Ellen M. Justice, MLIS, AHIP, medical librarian, for conducting literature searches; Dolores Ann Moran, medical library assistant II, and Janice Evans, medical library assistant II, for their assistance in locating articles; Norma Hollingsworth for secretarial support; and Robert J. Laskowski, MD, MBA, and Donald Riesenberg, MD, for feedback on the manuscript.
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56 Rosenberg H, Polonsky B. The role of nonphysician consultants as health-care educators in postgraduate programs of anesthesiology. Acad Med. 1990;65:119–122.
57 McGaghie WC, Kowlowitz V, Renner BR, et al. A randomized trial of physicians and physical therapists as instructors of the musculoskeletal examination. J Rheumatol. 1993;20:1027–1032.
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