Searle, Nancy S. EdD; Thompson, Britta M. PhD; Friedland, Joan A. MD, MPH; Lomax, James W. MD; Drutz, Jan E. MD; Coburn, Michael MD; Nelson, Elizabeth A. MD
“Our school needs an academy” is a declaration by educational leaders at many medical schools that sponsor academies of medical educators and at some that do not—yet. In distinguishing academies of medical educators from other faculty development/recognition initiatives, Irby et al1 describe academies as medical education activities that have (1) a mission that advances and supports educators, (2) a membership composed of distinguished educators, (3) a formal schoolwide organizational structure with designated leadership, and (4) dedicated resources that fund mission-related initiatives. Irby et al also suggest that academies are showing promise “for promoting teachers, supporting education, improving curriculum, advancing educational scholarship, and changing the culture of academic medicine.” With their schoolwide organizational structure, academies may facilitate fundamental cultural and structural reform of education. These reforms could put education back again at the center of academic medicine.1,2
Although the definition of a distinguished educator is determined differently by individual academies,3–7 each academy serves as a “mechanism for formal institutional recognition of teaching excellence.”2 In 2003, Dewey et al2 surveyed institutions concerning the prevalence and practices of academies in North America. At that time, the academies movement was in its infancy with 21 identified programs. Anecdotal evidence, predominately discussions with leaders from a variety of medical schools at the Academies Collaborative meetings held during the Association of American Medical Colleges' (AAMC's) annual meetings since 2003, suggested that the number of academies has grown significantly since the completion of the 2003 survey by Dewey et al.2
We based this research effort on the work of Dewey et al2 that examined the characteristics of academies, including the processes for admission, selection, and retention of academy members, the types of faculty who make up academy membership, program goals, benefits provided by academies to the individual member and to the institution, and funding sources and amounts, and to explore the increase in the number of academies since the survey by Dewey et al,2 which was completed in 2003. Other goals of this research effort were to
* determine if the benefits provided by academies to individual faculty members and the goals of academies begun in 2004 or later differ from the benefits provided by academies to individual faculty members and the goals of academies begun before 2004;
* examine the impact of the selection process (criterion-referenced or normative referenced) on individual benefits and program goals; and
* evaluate the relationship between funding sources of academies and the academies' budgets.
We, the authors, who are all involved in faculty development, adapted an existing questionnaire2 to survey academies nationally. The result was a 29-item questionnaire that elicited information about both the prevalence and description of academies at medical schools accredited by the AAMC. We used Dewey and colleagues'2 definition of an academy:
A formal organization of academic teaching faculty who have been formally (or specifically) recognized for excellence in their contributions to the education mission of the medical school, and who serve specific functions on behalf of the institution.... A functioning organization, not simply a group of recognized faculty.
Questionnaire items included closed-ended questions regarding membership eligibility, processes and criteria for selection, membership term and maintenance, reapplication process, award categories, program goals, funding sources and amounts, and benefits to the individual member and to the institution. The questionnaire was administered via the Web.
In April 2008, a link to the questionnaire was sent via e-mail to one medical education contact at each of the 127 medical schools that existed in the United States and its protectorates at that time, with instructions to have the individual at each institution who was most knowledgeable about faculty educational recognition programs complete it. We chose one contact at each medical school from one or more of the following sources: a list of contacts for each school obtained from the AAMC, faculty members involved in faculty development whom we knew, and faculty members involved in faculty development referenced by faculty members whom we knew. Follow-up reminders were sent one and two months later.
Questionnaire data were analyzed using descriptive statistics via SPSS 15.0 (SPSS, Chicago, Illinois). To determine differences between groups, both those established before 2004 and also those established in 2004 and later, we used multivariate analysis of variance using Hotelling's T-square with follow-up analysis using univariate ANOVA with Bonferroni correction. We were also interested in the correlation between the nomination and application processes of academies. To determine correlations between variables, we used both parametric and nonparametric analysis. Because both gave the same results, we present the parametric results (Pearson r). We set our alpha level at .05. To determine effect size, we used eta squared (η2). We chose to consider η2 values of 0.16 (or 16% of the explained variance) a strong effect, or educationally significant.8 Approval from the Baylor College of Medicine institutional review board was obtained before beginning the study.
One hundred twenty-two of the 127 schools (rr 96%) responded to the survey. Table 1 lists the total numbers and percentages of responses to the questionnaire in two categories: academies established before 2004 and academies established in 2004 or after.
Proliferation of academies
Thirty-six schools reported having academies; 31 of these were established in or after 2000. One academy did not indicate when it began; we omitted it from our calculations comparing programs that began before 2004 and in 2004 or later. The first academy was established in 1977. Since 2003, and as of our findings in 2008, 21 (58%) of the responding schools have initiated academies, 13 (36%) schools were planning academies, and 20 (55%) schools were considering the academy idea (see Figure 1).
On the basis of published and anecdotal evidence, we were interested in changes related to acceptance standards (criterion-based versus norm-based), membership terms (lifetime versus term limits), maintenance of membership requirements, nonmonetary benefits, monetary benefits, funding (funding versus no funding), and goals (number of goals selected). Multivariate analysis of variance indicated a statistically significant difference between academies founded before 2004 and in 2004 and later (P = .013, η2 = 0.457). Significant differences were noted for membership maintenance requirements, goals, nonmonetary benefits, and membership term limits.
Nomination to the academy was by a variety of methods, including by the department chair, the dean, or the school's president (25; 69.4%), another academy member (18; 50.0%), self-nomination (18; 50.0%), peers or learners (15; 41.7%), and learners' ratings (2; 5.6%). As part of the application process, most academies required those applying for membership to provide letters (29; 80.6%), application forms (27; 75.0%), and CVs (27; 75.0%). Surprisingly, fewer than half of them (16; 44.4%) required teaching portfolios. There was no correlation in the materials required of applicants for admission to academies with either a criterion-referenced or norm-referenced selection process. However, academies that allowed self-nomination also required submission of a personal statement (r = 0.335, P = .006). Analysis showed no other positively correlated requirements.
About two thirds (25; 69.4%) of academies use a standards/criterion-referenced method for selection of members rather than a norm-referenced method. Applicants can be measured against each other (norm-referenced) or against a published standard (criterion-referenced). The purpose of a norm-referenced assessment is to sort applicants rather than to measure achievement toward some criterion of performance. Norm-referenced evaluation ranks applicants and selects membership based on their rank; criterion-referenced evaluation compares the applicant against a specific standard. If the applicant is determined to have met the standard, he or she is admitted to the academy.9 We found no statistically significant difference in selection methods for those academies founded before 2004 or in 2004 or later.
Many (29; 80.6%) academies selected membership via a committee, and fewer than a quarter (8; 22.2%) of academies employed peer review or outside reviewers (6; 16.7%) in the selection process. Selection/inclusion criteria used to select members by more than two thirds of academies include quality of teaching (32; 88.9%), educational leadership activities (29; 80.6%), the development of educational materials (27;75.0%), quantity and quality of educational publications (25; 69.4%), and educational research efforts (25; 69.4%). Although in the selection process faculty members are recognized in a variety of categories by many academies, half of those that we studied (50.0%) had no specific categories for faculty recognition (see Table 1).
Membership activities and maintenance of membership
Thirty-four academies reported a total membership of 1,382 (range 5–215) individuals: 821 in academies established before 2004 and 561 in those established in 2004 or later. Two academies did not report the numbers of members in their programs. Once granted, membership was either for life (16; 47.2%) or for a set term between one to six years. Analysis indicated an educationally significant difference in the granting of life membership for academies established before 2004 and those established in 2004 or later (P = .012, η2 = 0.178). Of the 25 academies with maintenance of membership requirements, 19 required participation in teaching, 12 in educational leadership, 12 in mentoring of faculty and/or students, and 7 in educational scholarship activities. Eleven academies had no maintenance of membership requirements. Interestingly, we noted that significantly higher numbers of academies established in 2004 and later required maintenance of membership more often than did those established earlier (P < .001, η2 = 0.334; see Table 2).
Benefits to the individual and to the institution
Membership in an academy offers a variety of nonmonetary individual benefits, including schoolwide recognition (33 schools; 91.7%), networking/collaboration opportunities (28; 77.8%), participation in faculty development activities (18; 50.0%), weight in promotion/advancement decisions (18; 50.0%), and mentoring (14; 38.9%). All the academies responding to our survey provided nonmonetary benefits to members, such as those listed above. Overall, fewer academies offered any type of monetary benefit (28; 77.8%). These benefits included funding for educational development (16; 44.4%), monetary awards (14; 38.9%), and, to a much lesser extent, protected teaching time (3; 8.3%; see Table 3). We noted that the academies established in 2004 and later provided more nonmonetary benefits (P = .004, η2 = 0.231), such as faculty development opportunities, networking/collaboration, and mentoring for career advancement and skill development. We also noted that eight (57.1%) of the academies initiated before 2004 indicated that monetary awards were a benefit of membership, whereas only six (28.6%) of those established later provided monetary awards as a benefit. Other individual benefits, which could also be considered benefits for the school, included opportunities for members to discuss educational topics (28; 77.8%), educational grants to members (27; 75.0%), and educational scholarship opportunities for members (16; 44.4%; see Table 3).
Schoolwide services provided by academies included activities such as educational seminars/grand rounds (18; 50.0%); peer review for educators (14; 38.9%); educational consultation for the dean of education, dean of the school, or other educational decision makers (13; 36.1%), or for the curriculum committee (12; 33.3%); educational scholarship activities for the school (12; 33.3%); or educational grants to others in the school (9; 25.0%; see Table 3).
Funding and goals
Sixteen academies (44.4%) stated that they had annual budgets of $25,000 or less, and seven (19.4%) reported having budgets over $100,000. Whereas five academies reported that they receive no funding, 22 academies (71.0%) indicated that their funding was included as a line item in their school's budget. Other sources of funding included a dedicated endowment (9; 29.0%), private donations (8; 25.8%), departmental funds (4; 12.9%), and external grants (2; 6.5%; see Table 3). We noted a trend between line-item funding and academy budgets. Analysis indicated that academies with the largest budgets also tended to receive all or part of their funds from a line item in their school's budget. All seven schools with academy budgets >$100,000 per year had line-item school funding, whereas fewer than half of the schools with budgets <$26,000 had line-item school funding.
All but one school reported that they had stated goals that included stimulating educational innovation (29; 80.6%), developing the educational skills of faculty (29; 80.6%), providing mentoring (28; 77.8%), promoting collaboration (24; 66.7%), promoting communication (22; 61.1%), enhancing promotion for educators (23; 63.9%), and fostering curriculum reform (12; 33.3%). Interestingly, those academies initiated after 2003 had additional educational goals (P = .001, η2 = 0.267), with almost all those academies indicating goals of educational innovation, faculty development, collaboration, and mentoring more than those initiated earlier.
Discussion and Conclusions
Within the larger context of medical education, academies can be seen as innovative. Irby et al1(p270) said that
as long as departments are the primary locale of faculty incentives and support, we contend that the broader educational mission of schools of medicine will never flourish .... This structural problem requires a structural remedy. We suggest that this remedy could include the creation of a new organizational entity, dedicated to education and independent but supportive of existing departments .... Such entities, known as academies, have recently been established in a number of schools with encouraging results. Academies appear to attract high quality faculty and provide them with incentives to devote more time to the educational mission of the medical school.
Thirty-one of the 36 medical schools with academies in 2008 reported establishing their academies since 2000. One way to understand this growth is to look at it in terms of Rogers'10 diffusion of innovations research. In 1983, Rogers defined diffusion as “the process by which an innovation is communicated through certain channels over time among the members of a social system.”10 Theories about the diffusion of new ideas, beliefs, knowledge, practices, programs, and technologies—collectively termed innovations—have a 110-year evolutionary history. Dearing11 suggested that specific attributes of innovation are associated with innovativeness (i.e., early adoption): how effective and cost-efficient the innovation is in relation to alternatives, how simple the innovation is to understand, the fit of the innovation with established ways of accomplishing the same goal, the extent to which outcomes of the innovation can be seen, and the extent to which the adopter must commit to full adoption.
The degree of innovativeness of adopters depends on their needs and motivations. Innovators are the first to adopt in part because of the novelty, and they have little to lose; early adopters usually include opinion leaders who have positively appraised the innovation's attributes. The subsequent majority adopt because others have done so, and they believe it is the right thing to do—the imitative effect.11,12 The four schools that established academies before 1999 could be considered innovators. The 10 schools that established academies between 1999 and 2003 could be considered early adopters, and the 34 schools that have either established academies recently or are planning to establish them are part of the large majority that have decided it is “the right thing to do.”
With all of the individual and institutional benefits associated with academies, the question is not, “Why have academies flourished?” but “Why doesn't every medical school have an academy?” A further look at diffusion theory might help to answer part of that question. Adoption alone means very little, given the political and social activities inside organizations—in this case, medical schools. When “[adopters of] innovations work in complex organizations, attention and follow-through concerning implementation are at least as important as is attention on the initial decision to adopt.”11 Those involved in implementation have two options: They put the innovation in place as it is, or they change it so that it will better fit their needs. Every adopting organization is unique.13 Our research shows that there were almost as many iterations of academies as there are academies, because adopters have adapted the program to suit their needs and feel ownership of the idea, thereby increasing the likelihood of program sustainability.11 Pawson and Tilley14 stated, “Programs work ... only insofar as they introduce the appropriate ideas and opportunities ... to groups in the appropriate social and cultural conditions.”
Nomination and selection
Perhaps academies are established predominantly for recognition of distinguished educators because the information that prospective academy members are required to provide for acceptance into an academy is similar to what they are required to provide when they seek promotion and/or tenure. More than two thirds of the academies that responded to our study used nomination by a department chair, dean, and/or the president of a medical school for membership consideration, and three fourths or more of academies selected membership by a committee process and required applicants to submit an application form, letters of support, and a copy of their CV. Unlike promotion and tenure committees, which consider faculty members in specific appointment tracks or pathways,15 only half of the identified academies had selection categories (teaching, evaluation, research, leadership, the development of enduring educational materials) of membership.
An interesting finding of our study was that those academies that allow self-nomination for membership did not necessarily require submission of a biographical sketch, teaching portfolio, and/or a personal statement in which the faculty member can elaborate fully on his or her teaching activities and achievements. Many of the responding academies (25; 69.4%) did not select a “winner” or the few “best” people (norm-referenced) but instead had a standards/criterion-referenced approach in which those meeting the standard of “distinguished educator” are admitted. Also interesting is that whereas more than two thirds of the academies reported that they use a criterion-referenced selection process, fewer than half required the submission of a teaching portfolio.
Membership activities and maintenance of membership
All identified academies accepted full-time, clinical, and basic science faculty members who teach medical students. More than three fourths of the academies had members who teach residents, fellows, graduate students, and postdocs. Almost half of the academies had members who are part-time, and very few had fellows, residents, allied health, nursing, and/or dental faculty members in their programs. This is an expected demographic, because we surveyed only medical schools.
While almost half of those responding to questions about the term of membership stated that membership was “for life,” almost the same number had fixed membership terms of one to six years. Academies established before 2004 were more likely to have term membership. Term membership might encourage academy members to continue pursuing educational excellence and innovation, as posttenure reviews have done,16,17 whereas lifetime members might have the attitude that once admitted to the academy, “I no longer have to prove myself.” Concerning posttenure review, Ellis18 reported that senior faculty who had not undergone a regular career (promotional) review in many years reported that “it felt good to get positive feedback and professional validation from other colleagues” after having gone through the process.
Benefits available to the individual and to the institution
Those programs established before 2004 tended to offer monetary awards to individual faculty members and fewer nonmonetary benefits. Those programs established in 2004 or later offered nonmonetary individual benefits of recognition, faculty development, promotion, and networking.
Only half of the responding academies founded before 2004 used a criterion-referenced admission system, but more than three fourths of the programs founded in 2004 or later use this system for admission. Perhaps those programs offering monetary awards might have to limit the number of members admitted each year and might therefore use a norm-referenced admission process. It seems that newer programs are moving into other areas of benefit to members, such as allowing opportunities and resources to develop their educational skills.
Funding and goals
Few academies reported receiving funding from dedicated endowments, private donations, and external grants, which may indicate scarcity of opportunities, difficulty obtaining these types of financial awards, or the small amount of funding that might be obtained from these sources. It is also reasonable to believe that the more stable funding source would be a line item in an institution's budget and that academies with the largest budgets would receive funding directly from their institutions. In addition, a program that recognized faculty throughout the institution and that had a specific function in the medical school would be expected to receive little or no funding from departments.
The newer academy programs reported having goals of stimulating educational innovation, developing faculty education skills, providing mentoring, and enhancing collaboration, which were less likely to be found in older programs. The prevalence of mentoring and development of faculty education skills as a goal is another indication that academies are more likely now to provide faculty development rather than simply recognition. As themes and variations change in education, perhaps educational innovations are more in the mainstream than they were earlier, or perhaps there is a greater need now than before for faculty development and educational innovation.
Academies established before 2004 and those established in or after 2004
If a snapshot had been taken of an academy member in 2003, he or she would probably have been a full-time clinician, basic scientist, or research faculty member who taught medical students, graduate students, residents, postdocs, and/or other faculty. He or she would have been nominated for membership into the academy by either his or her department chair, the dean, or the president of the school. He or she would have been required to include an application form, letters of support, a CV, and his or her teaching portfolio. There would have been no selection categories in his or her academy, and the selection process would have been by a committee, using either a criterion- or norm-referenced process. The selection committee would have evaluated the quantity, quality, breadth, and time spent teaching, the educational materials the candidate had developed, educational leadership positions held, the number of articles published, and the quality of the journals that published them to determine admission. Once admitted to the academy, he or she would have been a member for life and would have found individual benefits in the academy of recognition, networking with other educators, and perhaps a monetary award. In addition, being in the academy would have helped him or her get promoted. The academy itself would have had goals of developing faculty educational skills, stimulating educational innovation, providing mentoring, and helping with promotion. The academy would have been funded through the medical school, and it would have provided educational grand rounds for the entire school.
If we can assume that little has changed since 2008, the year of our study, we can say that today, the average academy member is also a full-time clinician, basic scientist, or research faculty who teaches the same learners as his or her academy colleagues did in 2003. He or she might self-nominate or be nominated for membership into the academy by either his or her department chair, the dean, the president of the school, or another academy member. He or she will not have to include a portfolio, but will need a personal statement in addition to the materials that his or her 2003 colleagues needed. The selection process will be by a committee, using a criterion-referenced process. The candidate will be evaluated for admission using the same criteria as his or her colleagues in 2003, except that the time spent teaching will be less important and his or her participation in faculty development will be included in the evaluation for membership. Only half of the responding academies have categorical memberships. He or she will be less likely to have a lifetime membership. He or she will find individual nonmonetary benefits in the academy, including recognition, networking with other educators, and faculty development opportunities. He or she will receive no monetary award, but might receive funding for further educational development. Being in the academy will help him or her get promoted. The academy itself will have the same goals as it did for his or her counterparts who were academy members in 2003, except for additional goals, including fostering communication and collaboration. The organization will be funded through the medical school, and it will also provide opportunities to discuss educational issues and educational grand rounds for the entire school.
Limitations and future research
Although we sent the survey to known medical educators at each institution with instructions to forward the survey for completion to the individual at their institution who was most knowledgeable about faculty educational recognition programs, we cannot be certain that our instructions were always followed. We also assumed that academies established before 2004 have not changed substantially since they were established; further research is needed to find out whether this is correct. If individual academies have changed since they began, it would be beneficial to explore why and how they have changed. In three or four year, it may be interesting to look again at all of the new academies being planned or considered and determine the degree to which existing academies have been instrumental in facilitating cultural and structural change in medical schools and in putting education back in the center of academic medicine as Irby et al1 proposed.
Whereas the main focus of academies established earlier may have been to provide recognition to members, the greater focus of those established more recently is to develop faculty. Although this may indicate simply that all educators need faculty development, we were surprised about the faculty development focus if academy members are those “who have been formally (or specifically) recognized for excellence in their contributions to the education mission of the medical school.” These data raise important issues for academies: Are academies fashioned to provide recognition or faculty development for members, or both? In what proportion should these goals be pursued? Does one strive for an inclusive or exclusive membership? Do institutions requiring faculty development programs use the title of “academy” because it has an academic cachet? At the time of our study, 33 schools were considering or planning academies; what is the focus of their planning, and why: recognition, faculty development, or both? Napoleon noted, while talking about the Legion of Honor, that “for no amount of money will a soldier sell his life. Yet he will gladly give it up for a piece of ribbon.”19 In an era of scarce funding for education, academies may provide outstanding educators with recognition that meets their psychological needs and helps with their promotion and tenure. Another research opportunity would be to gather data about whether academies have or have not been successful in helping teaching faculty with promotion and tenure.
Finally, we have only touched on the barriers to the establishment of academies, using diffusion-of-innovations research as a theoretical basis. We suspect that although many medical educators agree that establishing an academy “is the right thing to do,” they are not the individuals who make the decision to establish an academy program. “In health care, invention is hard, but dissemination is even harder.”20 Some provocative questions remain: What are the barriers and facilitators to establishing an academy? This question, as well as one determining why some academies have failed, might best be answered using qualitative research methods. Ethnography, anthropology, and other qualitative methods are powerful ways to describe and inform about mechanisms and contexts that Rogers10 described in Dissemination of Innovations.21
The declaration, “Our school needs an academy,” might best be turned into a question: “Does our school need an academy?”22 We contend that institutions should plan wisely and well when beginning an academy program: determining goals, the application process, benefits to members and the institution, expendable resources, and means of support. The final product depends on the choices made at the beginning. Academies have the potential not only to recognize and support individual educators but also to put education back in the center of their sponsoring institutions.
The authors thank the respondents for their time and effort. They also thank John R. Searle, PhD, and Stephen B. Greenberg, MD, Baylor College of Medicine, and Charles J. Hatem, MD, Harvard Medical School, for their support, insights, and suggestions.
Approval from the Baylor College of Medicine institutional review board was obtained before beginning the study.
The opinions expressed in this report are those of the authors.
Oral presentations by Dr. Searle on this topic were given at the Academies Collaborative meeting in San Antonio, Texas, November 1, 2008, and at the Southern Group on Faculty Affairs meeting in New Orleans, Louisiana, April 3, 2009.