Dramatic shifts in society, health care, and educational practice have occurred over the century since the Flexner Report, and these shifts have resulted in changes and challenges for medical school faculty. In this article, I explain why medical schools must reconsider and restate the required characteristics and work of faculty members. I also recommend ways that individual schools and national organizations can advance the educational mission through support of the faculty and others who contribute to the educational program.
Introduction and History
Abraham Flexner is given deserved credit for championing the transformation of medical education at the beginning of the 20th century. Flexner's advocacy spanned multiple areas of medical education, including admission criteria, standardization of the curriculum, meaningful assessment, and governance structure. But one of the areas upon which Flexner's impact was most crucial was the professionalization of faculty members in colleges of medicine in the United States and Canada.
In the pre-Flexnerian era, most U.S. medical schools were independent, privately owned, and organized to make a profit for the owner.1,2 In these medical schools, the teaching staff usually consisted of the physician proprietor of the school and several other physicians. The primary work of the teaching staff was patient care, and it was from patient care that the physicians derived most of their income. Teaching was a secondary activity. Some teachers were talented and devoted; others were not. Many teachers did not show up for lectures, and some taught incompetently when they did. Even in the presence of lecturers, classrooms were often filled with rowdy students. Faculty-generated research and scholarly work were rare. The U.S. military and others recognized that many U.S.-trained physicians were not competent and that the care received by many patients was substandard and reflected out-of-date practices.
Americans who could afford to do so often pursued medical school or postgraduate medical training in Europe, where medical schools were housed in universities and medical school faculties included full-time basic scientists and physicians. European faculty members taught, conducted research, and (if they were physicians) could engage in clinical work. Collectively, the faculty community established the curriculum, standards of admission, and graduation requirements and both created and nurtured the academic environment in which students learned.
U.S. physicians returning after European (particularly German) medical education became champions of a more standardized and academic approach to education. Hence, by 1908, when the Flexner Report was commissioned by the Carnegie Foundation for the Advancement of Teaching, an important part of the agenda of leaders and organized groups in academic medicine was the professionalization of the faculty. Flexner became their most effective change agent, first through the power of his words and later through the monies he controlled at the General Education Board of the Rockefeller Foundation.3,4
Flexner advocated that medical schools be university-based with full-time salaried faculty members in basic science and clinical departments. In the years after his report, medical schools hired scientists who formed the early basic science departments, units that were incorporated into the traditional university faculty structure with relative ease. Physician faculty members were also hired and formed the clinical departments. Because of their patient-care responsibilities, hospital affiliations, and salary structures, these faculty members and their departments have never fit as easily into the traditional university structures as did the basic scientists.
Flexner recognized that patient care was a crucial aspect of a physician faculty member's identity and academic activity; he also believed that physician faculty members should be free of the necessity for earning a living through clinical practice if they were to have the time and energy necessary for pursuing their academic activities. He recommended that physician faculty members should receive salaries and should return any earned patient care revenues to the university. This full-time, salaried, physician faculty model was successfully implemented at the Medical Department of the Johns Hopkins University (today's Johns Hopkins University School of Medicine) and a few other well-resourced medical schools. However, the model was too expensive to be implemented at most medical schools. Gradually, two broad categories of full-time clinical faculty members emerged.5 “Academic” full-time (AFT) physician faculty members were full-time salaried faculty members whose patient-care revenues were returned to the school. “Geographic” full-time (GFT) physician faculty members were either employed by or affiliated with a medical school and were paid, in whole or in part, by the clinical revenues they generated.
This concept of full-time academic medical school faculty members was broadly adopted (at least in principle) and dominated medical education until the mid-20th century. Basic scientists pursued their science and also had substantial teaching responsibilities. Physician faculty members practiced in medical school-affiliated hospitals, often the charity hospitals that served patients who could not pay for care. Compared with private practitioners, faculty physicians spent less time in clinical care and treated a smaller number of patients. Their patients were selected, in large part, on the basis of the needs of the teaching service or the research interests of the clinician. These physicians spent substantial time teaching (prominent components of this teaching were bedside rounds and overseeing the clinical work of students) and doing research. A faculty physician might serve as a consultant to private practitioners in the diagnosis of unusual diseases or the treatment of particularly challenging patients, but these patients were returned to the care of the private physician, and economic competition between academic and private practice physicians was minimal.
By the 1950s, the role of medical school faculty members had been described, professionalized, and institutionalized. Although the size of medical school faculties had grown over the years since Flexner's report, the number of physician faculty members remained relatively small compared with the number of private practitioners. However, beginning with the implementation of Medicare and Medicaid in 1965, many factors—including dramatic shifts in health care funding, the reduction in charity hospitals, the creation of faculty practice plans, the explosion of research funding opportunities, the evolution of the academic health center (i.e., a medical school, one or more other health professions schools, and affiliated health systems/hospitals), the emergence of the community-based model of medical education, the universal adoption of graduate medical education, the emergence of the business of medicine and the business of research, and an increased reliance by both the medical school and the university on clinical revenues – have fundamentally changed the structure of academic medicine, the work lives of those who do academic medicine, and the way in which the role of a faculty member in a medical school is perceived.
The Shifting World of Academic Medicine
As we envision the role of the 21st-century faculty member in the educational process, it is important to recognize the seismic shifts that the academic medical system has faced and continues to face. These shifts, which Flexner could not have imagined, have had a great impact on medical education and on the faculty.
One important shift has been the movement from seeing medical education as four years of medical school spent in lecture, laboratory, and the hospital to seeing it as a continuum of lifelong education. In this new model, learning occurs in traditional and new settings (outpatient clinics, private practitioners' offices, and simulation laboratories, to name a few), and new pedagogical methods are used (e.g., technology, standardized patients, learning communities). The universal pursuit of graduate medical education and the requirements for continuing professional education have expanded the educational needs for which the medical school should be responsible. Over the past generation, in response to changes in societal need, educational theory, and technology, a number of works have stimulated ongoing innovation in medical education.6–12 A new Carnegie report on medical education, certain to stimulate additional conversation about how we educate the next generation of physicians, was released this summer.13
Largely because of changes in health care delivery systems and medical education funding, the structure of medical schools has shifted from that of an independent organization to that of an organization that works with partners in an interdependent system. Flexner was concerned about the medical school, and he sought to have the school embedded in a university system with an affiliated (preferably medical-school owned) teaching hospital, an arrangement that would foster the academic environment and support the missions of teaching and research. Today, no medical school can accomplish its mission independent of other organizations. In “traditional” medical schools, the school is a component of a university-affiliated academic health system. In community-based medical schools, the school may balance multiple affiliations with teaching hospitals that compete with each other. Proposed models of medical education include medical schools founded by, and embedded within, hospital systems, and investor-owned schools.14,15 With complex systems and interdependency comes the potential for conflict across organizations. And yet the medical school, the teaching hospital, the practice plan, the research institutes, and the other health professions schools cannot accomplish their individual missions without each other, and all of these organizations will achieve their full potential only by working effectively with each other.
Over time, the scope and emphasis of the medical school mission have shifted. Flexner advocated the primacy of the academic mission. He identified teaching as the essential mission of the medical school and believed that medical schools should be located in environments in which teaching is valued and students are mentored by excellent role models. Flexner championed research, not for its own sake but because research encouraged skepticism of orthodoxy, use of the scientific method, and the felt responsibility to discover new knowledge; these characteristics would, he believed, contribute to an academic environment that turned out better physicians. Over time, with expansion of research and clinical activities, medical schools adopted the model of a tripartite “three-legged stool” mission of education, research, and patient care, in which each of the three legs was equally important. In many environments today this mission has morphed into the tripartite “tricycle” model, with clinical service in the prominent (larger front wheel) position and the traditional academic missions of education and research in crucial, but secondary (smaller rear wheels) roles.
Perhaps the most substantial shifts for academic medicine have been the dramatic increase in the level of complexity of academic medicine and the accelerating pace of change. Flexner could not have anticipated the sheer volume of information that has become available; the evolution of medical practice, research, and education into businesses; and the complex interrelationships between the enterprises of education, research, and clinical care in the century after his report. Today, the amount and availability of information, the diversity of options, the numbers of interested parties, and the speed with which all of these factors change create an environment that is marked by change, complexity, and interdependent actors. We can anticipate that the ongoing redefinition of the U.S. health care delivery system and the continuing evolution of medical education practices in response to national need will add additional change and complexity to the system.
These shifts in academic medicine have combined with changes in society, health care, and biomedical research to create substantial challenges to medical school faculty systems and faculty members. The traditional advantages of the full-time faculty role, including the opportunity for tenure and the link between salary support and tenure, are decreasing.16 Some persons hired into non–tenure track roles experience more difficulties with promotion and feel less valued within their organizations.17 Common concerns include, but are not limited to, retaining physicians in academic medicine, the dedication of adequate resources to support the teaching and scholarly work of clinical faculty, the lack of diversity in the faculty and its contribution to the lack of diversity in the medical profession, disenfranchisement of faculty, and concerns about professionalism in an atmosphere of work-hour rules and intergenerational differences.18–21 Lack of clarity and transparency about expectations and roles result, on the one hand, in faculty members who want to practice in the cutting-edge environment of an academic teaching hospital but have limited interest in teaching and find that teaching expectations are an imposition; and, on the other hand, in faculty members who choose an academic career so that they can teach and pursue research but find that inadequate time and abundant disincentives keep them from the very activities that led them to choose an academic career. Without collective buy-in and a comprehensive view of the work of the medical school, misunderstandings and tension can occur.
It is perhaps not surprising, given the changes and stressors in the academic environment, that faculty describe themselves as demoralized.22 This attitude is also viewed as the result of living with an explicit curriculum that states that academic activities are valued and a hidden curriculum that treats teaching and scholarly work as intrusions into the more important work of revenue generation, and of worrying whether the mission of education is viable in today's health system environment. Demoralization is antithetical to a vibrant teaching environment and is very much an issue that must be addressed as we consider faculty for the 21st century.
All of these challenges keep faculty members, department chairs, and deans awake at night and spur institutional and national committees to develop a variety of responses. The evolution of mission-based management and compensation systems that incorporate relative value units (RVUs) for both clinical and education activities are two examples of mechanisms that have evolved to address funding and cross-subsidization questions.23,24 Movement toward an expanded view of scholarship and the plethora of new faculty tracks seek to balance the need for critical analysis of any request for faculty promotion or tenure with the recognition that there are many differing but crucial roles in today's complex academic health environment. The recent focus of the Association of American Medical Colleges (AAMC) on leadership development in medical schools and on the identification of exemplar search committee practices seeks to help institutions attract, retain, and grow academic talent.25,26 Academies for educators have been designed to promote recognition, community building, and professional development for faculty members who teach.27 These innovations and others have been helpful in addressing the problems, and the New Horizons Conference offers us the opportunity to propose additional responses.
One might wonder why so much attention is being paid to the faculty as we consider the education of this century's physicians. As we move forward in the 21st century, there is value in revisiting longstanding and fundamental principles that underpin medicine and medical education. Medicine is a profession. As a profession, it has characteristics and obligations beyond that of a business or corporation. Even though the practice of medicine has become corporatized in recent years, that does not change the fact that those obligations linked to being a profession should remain first and foremost. Two of these professional obligations are to act in a socially responsible manner and to educate the next generation of the profession's practitioners.
Medical schools and residency programs are the vehicles used by society and the medical profession to educate future physicians. Medical schools have three very important missions: research, clinical care, and education. Of the three, medical education (particularly undergraduate and graduate medical education) has always been, and remains, the essential mission of the medical school. This is the mission that is the basis of the social contract between medical education and the communities we serve; this is the mission for which no other organization exists.
The medical education process in medical school and residency includes the transmission of a great deal of knowledge and many clinical skills. But medical education is much more than this. A substantial part of medical education is tailored to instilling professional values (e.g., commitment to competence, acting in the patient's best interest) and developing behaviors consistent with those values in the next generation of physicians. If, as I propose, the education of aspiring physicians and of the most junior members (residents) of the profession is the essential mission of the medical school, then the reason for focusing so much attention on the faculty becomes clear.
Faculty is an academic title. Faculty members in medical schools are charged with the most crucial elements of accomplishing the schools' mission. Medical school faculty members are responsible for admitting students to medical schools and most residency programs, responsible for the curriculum, responsible for teaching and assessing learners, and responsible for recommending students/residents for graduation.28 The academic environment has been recognized as crucial to the education process, and faculty members have a special responsibility for creating and nurturing the academic environment. Hence, not only is it appropriate to focus substantial attention on the faculty in the educational process, but it would also be inappropriate not to take this opportunity to address challenges to our faculty systems and to develop new approaches to helping faculty become happier, more productive, and more successful in the 21st century.
Faculty members do not work in isolation. A cadre of medical education and student affairs professionals, administrators, teachers (physicians and nonphysicians), patients, community members, and others play crucial roles in the process of educating the next generation of physicians. Most medical schools (both traditional-model and community-based) are interdependent members of academic health systems. Therefore, it is not enough that medical educators or even the members of the entire medical school community engage in this discussion.
Traditionally, medical schools, teaching hospitals, other health professions schools, and the various other elements of our academic health enterprises have existed in silos. This balkanization of units contributes to the mixed messages received by, and to the tensions experienced by, faculty members. We must engage our partners in the various academic health enterprises of which medical schools are a part. Accomplishing such engagement may be challenging, especially for community-based schools. However, a good outcome demands that members of the entire enterprise understand the educational mission, the importance of this mission to the medical school, and the contributions that the educational program makes to the success of other components in the larger system. Numerous examples exist in which an integrated academic health enterprise acting in concert has improved all of the mission outcomes, including medical education, to a degree that was not previously possible for any single component of the enterprise.29–31
Four Opportunities for Advancing the Educational Mission Through Support of the Faculty
As noted previously, faculty members experience challenges in the current system, and the faculty system itself is not working as effectively as it should. In this section, I will focus on four crucial areas that require attention: restoring academic meaning to the faculty title, improving the diversity of the faculty, enhancing faculty development, and defining scholarship for the medical profession and for medical educators. Progress in these areas in the next five years has the potential to make a positive difference in our medical schools and the faculty.
Restoring academic meaning to the faculty title
A medical school faculty title has always been, and remains, highly attractive and prestigious. In the past, faculty membership was limited to a relatively small group of people. A faculty title suggested that the holder of this title was highly competent and was a resource for others in a particular clinical or scientific discipline, dedicated a substantial amount of professional effort to teaching students and pursuing scholarly work, and had a strong relationship with a medical school. Today, however, faculty membership is granted more readily to a larger group of people with much looser connections to the school. Many holders of this title do little or no teaching; in some cases, in fact, their contract precludes their teaching. As medical school clinical enterprises have grown and as medical education has moved into community settings, faculty titles have been granted to persons who are geographically distant from the main campus, responsible to administrators outside the medical school, and minimally involved in the academic activities of the school. This creates challenges for clinical, research, and educational operations of the medical school as well as for the faculty member.
The expansion of reasons for granting faculty status has led to a plethora of new faculty titles. A few terms used as descriptors in these titles include tenured, tenure eligible, research, clinician-educator, voluntary, special title, community-based, and clinical. This multitude of titles contributes to a lack of clarity about expectations on the part of the faculty member, the department chair, and the academic community, with resultant communication problems and tensions. There is an increasing disconnect between the faculty title, the faculty member's responsibilities to the medical education program, and the school's responsibilities to the faculty member. We are at risk for the faculty title to become meaningless.
This challenge presents an opportunity to rethink the ways in which we construct the medical school faculty. It takes many persons acting in varied roles and accomplishing important work of high quality to ensure the successful operation of a medical school, its partner teaching hospitals, and its associated research efforts. It is important that all of these persons are recognized and valued for the work they do. However, we must develop ways of recognizing all of the persons who contribute while at the same time differentiating those persons who bear the substantial responsibilities for the academic mission that are implied by the faculty designation. It is crucial that we reinstill meaning into the term faculty member and that such meaning specifically relates to academics in general and to teaching in particular.
For the sake of discussion, I propose that we reconstruct our current faculty into three categories, with expectations, engagement, and support tailored accordingly. The first category would consist of persons who provide important contributions to our schools and their missions but have limited engagement in the academic missions of teaching and research. This group would be recognized as mission-contributors and designated as teachers, researchers, or clinicians.
The second category would consist of persons who combine disciplinary excellence, a substantial contribution to at least one of the three missions of the medical school, and substantial engagement in the academic work of the school. This group would constitute the faculty.
The third category would consist of persons who combine disciplinary excellence, a substantial contribution to at least one of the three missions of the medical school, substantial engagement in the academic work of the school, and a particular commitment to the educational program of the school. This group would constitute the core faculty. In the more detailed descriptions of these categories below, I have used the present tense because there are already individuals carrying out the tasks and responsibilities required in these categories.
Let us first consider the mission-contributors. Mission-contributors include several groups of people. One group includes persons employed by, or affilitated with, our medical schools and academic health systems whose work is limited to clinical care or research and who have no (or very limited) engagement with students (medical, resident, graduate). Another group includes private practitioners and other professionals who provide educational services (voluntarily or for small stipends) for a limited amount of time – for example, by giving several lectures, teaching a clinical skills session, or serving as a preceptor for a student or a resident for one session each month. Both groups include persons who are very important to the work of the medical school, and they should be recognized, engaged in the medical school community, supported in their work, and valued. However, the volume or nature of their work does not merit a faculty appointment and the responsibilities that accompany that role.
Explicit recognition of mission-contributors in their roles as clinicians, researchers, and teachers is important because it acknowledges their relationship with the school and the responsibilities of each party in the relationship. At a minimum, schools should expect mission-contributors to do quality work, to make a contribution to the school's mission that is proportional to the amount of time for which they are engaged, to provide learner-centered teaching or (if not teachers) to be hospitable to learners, to practice lifelong learning, and to exhibit professionalism. On the other side of the coin, mission-contributors should expect to be engaged and valued members of the school community, to receive feedback about their performance, to have opportunities for professional development related to their medical school duties, and to receive administrative support appropriate to the work that they perform.
Next, let us turn to a discussion of those persons who would hold faculty titles. In general, these faculty members are actively working in one of the disciplines related to the work of the medical school. Although some faculty members are retired from active practice, they must remain up-to-date and highly knowledgeable in their disciplines. Each has achieved a defined level of experience in his or her discipline and is highly competent. Although some critics may be concerned about the “Lake Wobegon Effect”32 of such an expectation, the faculty of a medical school should not, in fact, be composed of average individuals.
Those persons whom I would designate as faculty have many characteristics in common with mission-contributors; however, they are substantially more engaged (time and activities) in the medical school than are the mission-contributors. Faculty are responsible for both creating and nurturing the academic environment. They should exhibit an evidence-based and scientific approach to their work, habits of lifelong learning, and a learner-centered approach to teaching. If they are clinicians, they must model a high level of medical professionalism. They are defined by characteristics such as teamwork, civility, leadership, and excellence. In other words, faculty must be explicit role models for the learners they teach. When such expectations are met, the hidden curriculum experienced by our students will cease to exist.
All faculty need to make a substantial contribution to the academic work of the medical school. This contribution includes teaching, scholarly work, and service. Scholarly work encompasses the definition provided by Boyer, consisting of research, application, integration, and education.33 The dean and the department chairs are responsible for ensuring that all forms of scholarship are present in the medical school environment and that each faculty member would have the professional development necessary for success in the scholarly area that has been defined. Faculty contributions to, and responsibility for, the educational mission of the school should extend into committee work, mentoring activities, and other service contributions.
There should be reciprocal expectations between the school and the faculty member. It is important that faculty workloads include adequate time for teaching and scholarly work, even if the majority of a particular faculty member's time may be spent providing clinical care. The amount of time necessary for these academic activities will vary with the faculty member, but it seems unlikely that this could be less than 30%. Many faculty members, particularly those with large externally funded research programs and those whose scholarly work is not closely related to their day-to-day activities, would need substantially more than this amount of devoted time.
Finally, let us turn to the third group – the core faculty. These persons must be outstanding both in their disciplines and in their activities as educators. The core faculty include those faculty members who are most engaged in the essential mission of the medical school – the education of medical students and residents.
Core faculty come from the faculty group and must meet all of the characteristics defined for that group. In addition, however, core faculty have a passion for teaching and working with learners, an interest in making education a key aspect of their professional careers, excellence in, or the promise of excellence in, teaching, a practice of lifelong learning both in their discipline and in teaching, a genuine commitment to students, and professional and personal demeanor and behavior that make them appropriate role models for medical students and residents. Core faculty spend the majority of their professional activities in teaching, administration, and scholarly work related to the educational mission.
Core faculty play important educational leadership roles within their own departments and units, and they also play important institutional roles as the experts and leaders of the educational mission. Within their own disciplines, they serve as important role models, mentors, and resources for educational practice, both formally and informally. One particularly important role is developing residents as teachers, an activity that enhances both undergraduate and graduate medical education and may also provide a mechanism for identifying the next generation of academic physicians. At the institutional level, the core faculty plays prominent roles in developing new pedagogies, evaluating the curriculum, working with other health professions educators on interprofessional program development, assessing students, advising students, and mentoring faculty members and teachers in educational work. This arrangement develops cross-disciplinary educational expertise, fosters innovation, and facilitates the development of a learning community among educators.
Scholarly productivity is an important element of the core faculty member's work. For some core faculty members, their scholarly work relates to their disciplines. Other core faculty members, particularly those in educational leadership roles, pursue education scholarship. Although it is important that education scholarship occur within all medical schools, it is not appropriate to expect that education scholarship be limited to the core faculty or that members of the core faculty be limited to the scholarship of education. It will be important for the medical school to have a common understanding about the nature of educational scholarship.
Developing a core faculty is especially important at this time in medical education. Public funding of higher education (including medical education) has been decimated by the recent economic collapse, and it is likely that the emerging health care system will place further constraints on clinical revenue models.34 We must be prepared to help the faculty be effective and fulfilled teachers, even in a time-constrained and high-pressure clinical environment. Clinical education is moving away from the bedside, and we must determine the correct balance between education that involves clinical substitutes (standardized patients, simulation) and education that includes patients, and then we must rigorously ensure that medical students continue to learn from real patients. Work-hour tensions, generational differences, and learner-centered education are creating stresses within training programs; having within a school a cadre of core faculty who are respected within their disciplines and who have the energy, enthusiasm, and expertise to address these and other educational challenges is very important. Furthermore, the presence of a core faculty contributes to exemplary practices and ongoing innovation in the educational programs of the school.
The importance of the designations described above.
The object of this redefinition of the faculty is two-fold. First, this redefinition is intended to recruit and develop an outstanding group of scientists, clinicians, and others who are engaged in the academic work of teaching and scholarship and to give them the responsibility, time, and tools necessary for performing this work. Furthermore, this system would link faculty status with the academic components of the health system. The requirements reprofessionalize the faculty role, making it a substantial component of the person's professional identity rather than a nice title with a limited and confusing meaning. Even with these requirements, a variety of working arrangements and faculty member–medical school relationships are possible. While it is likely that most basic science and clinical faculty members would be full-time medical school employees, part-time employees and voluntary community-based physicians could meet the requirements for faculty status.
Second, this redefinition is intended to identify, recognize, and reward the many individuals who are critical to the work of academic medicine and who wish to be engaged in the various missions of clinical care, research, and education but who do not seek (or are not assigned) the duties and responsibilities that accompany the faculty title. If broadly adopted, the mission-contributor titles of medical school researcher, clinician, and teacher can provide deserved recognition to these individuals. Further, this system will promote the development of professional development opportunities, expectations, and rewards systems tailored to individuals who fill these roles.
Changes in faculty systems such as those I have proposed are likely to create some uproar. Few people will want to relinquish faculty status without assurances that there is still a place for them within the medical school community. Education administrators will not want to risk losing the contributions of those volunteer physicians and other educators who provide small amounts of valued service. Some people may worry that a changed system will be exclusionary or elitist. At the same time, this new model may be greeted with applause by talented teachers who wish to be engaged in teaching and precepting on a limited basis and who currently have had no viable and valued organizational options except to join the faculty. Researcher and clinician mission-contributors may welcome a title that can incorporate unique aspects of their contributions to the school. The new model will benefit all newcomers to our organizations, who will have greater clarity about the expectations of the roles for which they are hired. Hence, although changes such as these may create some initial disquiet, they will help reinstill meaning into faculty status. Furthermore, the changes will allow us to better tailor support and professional development activities to the overlapping, but not identical, needs of mission-contributors, faculty, and core faculty. Movement toward a new structure will require consensus among medical schools, and a transition period may be necessary. However, for the overall health of the faculty role and the academic missions of education and research, a reconfiguration and redefinition of the faculty must occur.
Improving the diversity of the faculty
The diversity of the medical profession as a whole, and academic medicine in particular, does not represent the racial, ethnic, or socioeconomic diversity of the U.S. population.35–37 In fact, on a per- capita basis, there are fewer physicians from groups underrepresented in medicine today than a century ago!35 This lack of diversity is particularly poignant given that Flexner's report contributed to the closure of most of the medical schools in operation in 1910 that focused their educational efforts on black students. The loss of generations of black physicians has had a substantial multiplier effect on health care disparities and the lack of diversity in medicine. Women continue to be underrepresented in certain specialties and in the leadership ranks of academic medicine.37–39 Recent studies demonstrate that medical school, like much of the higher education in the United States, is the province of the wealthy.40 In addition to the moral issue represented by this lack of diversity in medicine, the business literature suggests that academic medicine is weakened by the limited viewpoints and approaches to problem-solving that accompany a lack of diversity among the decision makers.41
Medical schools can take numerous actions to improve the diversity of their faculty communities. First, schools must continue activities that increase the diversity of their student and resident groups, because our future generations of academic medicine faculty will come from these groups. All medical students and graduate students should learn about academic medicine, and special attention should be directed toward students who demonstrate interest in or have qualities that suggest that they will be assets to the academic medicine community. All promising residents should be given the opportunity to learn more about an academic career. Because of the small numbers of faculty who are from groups underrepresented in medicine, it may be helpful to specifically address the reasons for this situation with promising residents, and it may also be helpful to assist them in gaining contacts and role models outside the organization.
As a rule, academic salaries are lower than the salaries for physicians in private practice and for scientists in industry. Hence, schools should consider loan forgiveness programs and other methods to ensure that educational debt does not compromise the selection of academic medicine as a career. Retention rates are lower for minority faculty members than they are for other groups.36 We should not overburden any junior faculty member with service responsibilities, and must take particular care that, in our quest to improve the diversity of our institutional committees we do not overburden early career faculty members from groups underrepresented in medicine. In addition, school leaders should work to ensure that all faculty members have appropriate ongoing mentoring support, and that faculty members and their families have multiple welcoming opportunities to be engaged in school-based and community social activities.
Although medical schools must continue and expand programs to improve the diversity of their student and faculty communities, the demography of academic medicine will not change substantially without the engagement of many others, including national organizations. The Aspiring Docs program of the AAMC is an excellent example of a program with national impact that is focused on marketing the medical profession to young people from groups underrepresented in medicine.42 Medical schools must be able to admit at-risk students—a group that may have more challenges with standardized examinations, a slower path through medical school, and more debt—without the concern that such outcomes will place the school at risk with accreditation surveyors. The Liaison Committee on Medical Education (LCME) can assist in reassuring schools through its educational programs, informational materials, and annotation of standards.
A national goal should be to increase the numbers of high school graduates and college students from groups underrepresented in medicine and from socioeconomically disadvantaged situations. Many of these students may choose medicine as a profession; others will find their way into other professions and careers, many of which are also inadequately diverse. Foundations and other funders should consider supporting a larger number of programs that identify talented students in the primary grades and middle school and provide support (economic, educational, and social as necessary) to those students and their families through high school into college. The AAMC and the Association of Academic Health Centers (AAHC) have a unique opportunity to work with other higher education and secondary school organizations to develop an initiative to increase the numbers of students from underrepresented groups in medicine and the health professions.
Enhancing faculty development
An important issue in supporting faculty and mission-contributors is adequate professional development. Faculty members, including core faculty members, need professional development support in three areas: remaining current in their disciplines, succeeding in the university advancement process, and teaching effectively. Mission-contributors have professional development needs that intersect with, but are not identical to, the needs of faculty.
First, faculty members must remain current in their disciplines. Such faculty development is usually provided within a department and is also available from discipline-based organizations. Ensuring that faculty members have the time and expectation to participate in these sorts of training (which, increasingly, are made available in multiple formats) is an important job of the academic chair. For interested faculty members, the AMA Section on Medical Schools offers a mechanism to become engaged in policy development about topics that span all areas of medicine and medical practice.
Second, faculty members must have the necessary skills for achieving academic success. New faculty members' exposure to academic life may include time as a graduate student, chief resident, or fellow, but generally their knowledge of the intricacies of academic life are limited. Faculty development needs in this area vary but may include learning to negotiate for, and maintain, the time necessary for scholarly work; time management; grant development; scholarly writing; understanding promotion expectations; and ensuring that the faculty members receive timely, candid, and constructive feedback about their progress. An important developmental need for many junior clinical faculty is research training: clinical care expectations and work hour rules have markedly reduced the research experience of residents and fellows.
Faculty members and the mission-contributors who participate in teaching are likely to need faculty development related to education. Some will have had experience teaching as residents and graduate assistants; a few may have received specific training in teaching. Faculty development needs in teaching are both specific (e.g., knowing the objectives of a specific course, clerkship, or teaching session) and general (e.g., working with the varying learning styles of students). Helping new faculty understand that, to be most effective, the teaching style should vary with the level of the learner and the objectives of the session, and then helping faculty members develop skills for meeting this goal, are important elements of a faculty development program. Additional topics range from using technology in teaching, to developing techniques for integrating clinical teaching within a busy practice setting, to assessing student performance, to working with multigenerational teams, and to using the resources of the dean's office to effectively help students, among others. The number and variety of important topics highlight both the need for developing faculty and mission-contributors as teachers and the importance of having a core faculty with specific expertise in teaching.
The core faculty, and mission-contributors and faculty members who aspire to join the core faculty, will have more substantial needs for faculty development in both the activity of teaching and topics related to education. For example, topics such as leading change, managing the curriculum, conducting educational research, evaluating programs, and mentoring teachers may be of particular importance to those faculty members who anticipate making education their career focus. Some medical schools have developed specialized curricula for faculty members who are focusing their efforts on education; other opportunities may be offered within schools of education on the same university campus.43
No discussion of professional development in teaching would be complete without discussing the needs of residents. It is well recognized that residents and fellows provide a substantial amount of teaching to medical students and junior residents. Consistent with requirements of the Accreditation Council for Graduate Medical Education (ACGME), most residents receive some training in how to teach. However, specific attention to the teaching skills of residents will help improve the educational experience of students, will help identify residents with particular interest and talent in teaching (with the hope of attracting them to an academic career), and may improve residents' ability to effectively teach patients throughout their careers. Curricula have been developed to improve residents' teaching skills, and these or other programs can be used to address this important need.44,45
Recent educational innovations include integrating the undergraduate and graduate medical curricula to graduate primary care practitioners one year earlier than is possible in a nonintegrated program, training interprofessional teams, and providing avatar-based simulated-patient experiences. Faculty development in these and other emerging topics, faculty development to support effective teaching in an efficient manner in the fast-paced clinical environment, and continued innovation in teaching methods support the need for robust faculty development programs to support mission-contributors, faculty, and core faculty with their overlapping, but not identical, learning needs.
Defining the scholarship of academic medicine
In addition to teaching, the work element that distinguishes faculty members from nonfaculty professionals is scholarly work. A primary reason that Flexner advocated placing medical schools in universities was the supportive atmosphere for research – one form of scholarship. Flexner's support for research in medical schools was focused not on the economic benefits or reputational impact that such research would bring to the medical school, but rather on the intellectual vitality related to ongoing questioning, hypothesis generation, and development of new knowledge.
The traditional views of scholarship were limited to research as discovery of new knowledge. Recognizing that this definition was too narrow, Ernest Boyer offered a model of scholarship that recognized four types: discovery, application, integration, and teaching.33 These four types of scholarship have substantial areas of overlap, and an investigator may produce work that fits into more than one type of scholarship. Subsequent to the description of the four types of scholarship, Glassick and colleagues publicized six elements that distinguish work as scholarly.46 Simpson and colleagues reported on the conclusions of a consensus conference that detailed the characteristics of teaching scholarship in medical education.47 Materials such as these can help faculty, promotion and tenure committees, and others better understand the rigor required for any scholarly work.
The scholarship of discovery (research) remains a prominent activity, and the best understood type of scholarship, in medical schools. However, the nature of clinical practice, the expansion of biomedical research beyond traditional disciplinary boundaries, and community engagement activities that are common in medical schools make the scholarships of integration and application likely in medical schools. Many medical educators pursue the scholarship of teaching. There continues to be discussion about the characteristics of various forms of scholarly work, the overlap and distinction between excellence and scholarship, and the ways in which institutions can appropriately expand their definitions of scholarship while maintaining rigorous expectations.
The Council on Academic Societies of the AAMC was an early champion of the expanded definition of scholarship in academic medicine.48 The Group on Educational Affairs of the AAMC has been at the forefront of promoting educational scholarship, and the MedEdPORTAL project has helped provide educators with a vehicle for sharing educational products and gaining feedback on those products.47,49,50 A number of institutions have formally incorporated the four scholarships into their promotion policies and practices, and tools such as education portfolios have been developed to help faculty members demonstrate their scholarly work.48,51 Still other institutions have developed learning communities to promote faculty scholarship and provide assistance to faculty members engaged in scholarly work.
It is important that scholarly work be done in medical schools, not only for the qualities it brings to the academic environment but also for the persons who are attracted to academic medicine because of their interest in pursuing scholarship. Faculty scholarship of all types should be supported at the institutional level with appropriate faculty development programs, research infrastructure support, financial support, and dedicated time to allow faculty members to do scholarly work. Peer-reviewed publications and external research funding continue to be common ways to demonstrate scholarship; faculty development and mentoring programs directed toward successful publication and grant development are important for all faculty members of whom scholarly products are expected. Institutional leadership should ensure that there is a common understanding across the institution about the definitions of scholarship and the institutional policies about scholarship. Furthermore, practice must be consistent with the policies.
As institutions consider their approaches to scholarship, looking beyond the borders of the medical school may be of value. For example, faculty members in conservatories and arts schools must produce scholarly products that are deemed to be meritorious. Promotion and tenure committees in these schools (and in their universities) consider less-traditional measures, including program rankings, invitations to perform, student recruitment, gallery placements, and ticket and CD sales in addition to the more traditional measures of papers published and grants obtained.52 What implications, if any, do measures such as these have for the work we do in medicine? We may find important insights in the practices of others. Beyond individual institutions, it is important that faculty members, the Council of Academic Societies, and others advocate the recognition of multiple scholarly forms, particularly the recognition of the scholarship of teaching, within academic societies and disciplinary groups.
Support of the Faculty—The Roles of Institutions and National Organizations
Enhancing our educational programs through support of the faculty will require the engagement of many constituents. Faculty members and teachers must be supported within their institutions. National organizations and foundations can assist by fostering conversation, fashioning draft policies and innovative models, and reducing barriers to change.
A valuable first step is for medical schools, health systems, and national organizations to reaffirm the principles stating that medicine is a profession, that medical education is part of medical schools' social accountability, and that education is the essential work of the medical school. The detailed interpretation of each of these principles may vary across institutions, but an explicit reaffirmation of the value of medical education and its importance to all missions of the academic health system is important during this time of challenge and change.
Medical schools must actively support an academic environment. If faculty members are the creators and the guardians of the academic environment, then the dean must surely take the leadership role in articulating the values of—and the value of—the academic environment across the academic health system. It is important that crucial elements of the academic environment—time to teach and do scholarly work; involvement of faculty in academic decisions and governance; tolerance of alternative viewpoints; lifelong learning; and engagement with students —be supported. Although it is likely that faculty members will accept somewhat lower salaries those earned by colleagues outside academic medicine, resources must be reinvested in the academic environment. In addition, all faculty members must be expected to, and must be given the tools to, excel and progress both in their disciplines and as teachers. All others engaged in teaching (residents, preceptors, occasional lecturers etc.,) must be given opportunities to become better teachers.
A crucial element of supporting the academic environment will be the financial support of the educational mission. Medical education is an expensive undertaking. Revenues related to tuition and public support of medical schools and residency programs should be directed to the educational mission. Because of the benefits that the medical school and the academic environment bring to practice plan members, teaching hospitals, and universities, it is appropriate that there be continued support of the educational mission and the school's academic infrastructure (research and education) through clinical revenue dollars and other sources. The current economic crisis and the changing model of health care will require that all components of the academic health enterprise develop a coordinated approach to funding all missions and that together they advocate the necessary public funding of the educational mission.
Financial support of the educational mission extends to salary support for the academic activities of the faculty. Core faculty members, in particular, are likely to generate a smaller amount of clinical revenue because of their contributions to the educational mission. Nonetheless, core faculty members' salaries should reflect parity with the salaries of other faculty members in their respective disciplines. If core faculty members' salaries are substantially lower because of differential participation in clinical or research revenues, then consideration should be given to providing these more-traditional faculty members with compensation elements that are traditional in higher education but not typically found in medical schools. Examples may include paid sabbaticals, dependent education benefits, long-term contracts, and the opportunity to earn tenure.
To keep the best young core faculty members engaged in the medical school, it will be important to define career tracks that provide stability and the opportunity for advancement. In addition to recognition and career paths within an institution, it is important that the core faculty, with their emphasis on the educational mission, have opportunities for career development and recognition at the national level. This begins at the institutional level with an atmosphere that embraces teaching, recognizes various forms of scholarship, and encourages education-related scholarship. Discipline-based education groups have flourished in the past two decades, and the involvement of core faculty in these groups and in national education groups (AAMC Group on Educational Affairs, Group on Student Affairs etc.,) should be encouraged. Election of the premier educators in academic medicine to the National Institute of Medicine is in order.
National organizations and foundations can support and advance the educational process and the engaged faculty members by initiating large-scale activities, sponsoring thoughtful conversations, and developing consensus on key questions. The New Horizons Conference is one example. A National Center for Health Professions Education Research has been proposed, and an education research collaborative sponsored by the American Medical Association (AMA) has begun its work.53,54 These are examples of large-scale activities that are best hosted by national organizations. Through the accreditation process, the LCME maintains the excellence of medical education programs in the United States. The LCME and the ACGME should consider whether current standards adequately incorporate the multiple types of teachers that provide training to our medical students and residents. National organizations and academic medical leadership must continue to encourage specialty societies to support and recognize scholarly work in education.
Conclusion and Recommendations
Medical education is the essential mission of medical schools, and faculty members are an essential element in accomplishing that mission. Many challenges exist for our faculty systems. The following recommendations may provide material for discussion at the AMA/AAMC-sponsored New Horizons Conference and for discussion within other constituencies of academic medicine. In general, these recommendations are intended for national organizations, foundations, and constituent groups as well as local institutions. To be successful at the local level, a number of these recommendations require advocacy and support from the national level.
There should be an explicit and public reaffirmation of relevant foundational principles such as the nature of medicine as a profession, the social accountability of medical schools, and medical education as a responsibility of the profession and the essential function of a medical school. Discussion about the meaning and implications of those principles should follow.
There should be a reconfiguration of the titles given to persons who contribute to the many missions of medical schools and academic health systems. Mission-contributors (teachers, researchers, and clinicians), faculty members, and core faculty members should be distinguished from each other; academic responsibilities, professional development programs, and other relevant items should be tailored to the needs and responsibilities of each group. When appropriate, career paths within these groups should be developed.
All faculty and core faculty members should be engaged in teaching and scholarly work. Faculty time, effort, and work product expectations should incorporate teaching and scholarly expectations. Faculty members must be given the release-time and the tools necessary for success, with the understanding that they must use these resources appropriately and meet the expectations of their roles.
National organizations involved in medicine, nursing, pharmacy, dentistry, public health, and the allied health professions; national foundations engaged in health professions education and health care delivery; and national organizations engaged in middle school, secondary, and higher education should develop a joint initiative designed to increase the number of well-prepared, college-bound students from groups underrepresented in medicine and from socioeconomically disadvantaged groups by 50-fold by the year 2030. Such a program must be available to students by middle school and should involve co-curricular and curricular activities. The program should incorporate elements of mathematics, sciences, and the humanities so that students will be attracted to and capable of pursuing a career in medicine and the other health care disciplines; however, the curriculum should also prepare all students for an alternative career path if that is their choice.
The AMA, AAMC, AAHC, LCME, and ACGME should develop a combined exemplary-practice resource to highlight programs that are particularly successful in recruiting, retaining, and promoting medical students and faculty who are women and/or who are from groups underrepresented in medicine.
The AAMC (Council on Academic Societies, Group on Educational Affairs, Group on Faculty Affairs) and the AMA (Section on Medical Schools, Council on Medical Education) should consider an updated resource on models of scholarship that includes exemplary practices and policies and that specifically discusses the four forms of scholarship as they relate to clinical practice and medical education.
National organizations should develop benchmarks, metrics, and tools to assist schools in tracking and demonstrating financial expenditures related to the educational mission, faculty (and mission-contributor) time and effort related to the educational mission, and institutional investment in faculty development. To the degree possible, accrediting bodies should use these metrics to help assess school efforts to fulfill their educational missions in undergraduate and graduate medical education.