Sherbino, Jonathan MD, MEd; Frank, Jason R. MD, MA (Ed); Snell, Linda MD, MHPE
The number of physicians in-training is increasing in response to a perceived shortage of doctors.1 This growth is taking place in an era of increasing accountability, in which the medical profession must justify societal investment by demonstrating quality in both training and practice. In response, medical education institutions are adopting new accreditation and assessment standards2,3 and a competency-based approach to learning.4 To meet these challenges and changes, the profession requires a cadre of physicians with advanced expertise in education, who can serve as consultants and leaders in medical education: that is, clinician–educators (CEs).5
The definition of clinician–educator varies considerably within the small body of published work that describes this role,5–8 and the precise scope of abilities or competencies for 21st-century CEs has not been established. The roles described for CEs—both clinical (e.g., physician in practice versus full-time educator) and educational (e.g., clinical teaching versus education design)—are heterogeneous, inconsistent, and often undefined. Further, there is little consensus on the optimal preparation of CEs or the key tasks that they perform.
Currently, three distinct pathways for the acquisition of expertise in medical education are open to physicians: (1) informal, ad hoc training (e.g., faculty development activities, specialty society courses); (2) fellowship training (e.g., formalized programs certified locally by universities or academic health centers); and (3) graduate education programs (e.g., master’s, doctoral). Informal training typically lacks a broad, comprehensive curriculum and standardized assessment of participants, so the abilities acquired are often mixed. In contrast, formal training requires candidates to invest a protracted period of time and often involves theoretical content that may have limited practical application. As well, within these routes, there is considerable variability in content, process, and expected outcomes.9,10
In this study, we set out to define the desired scope of competence of a 21st-century CE. Using a mixed-methods approach, in which findings from focus groups informed a national survey of Canadian medical education leaders, we sought to determine the current consensus of opinion with regard to the following questions:
1. What is a CE?
2. What core competencies are needed for contemporary CE practice?
3. What type of training or preparation is viewed as optimal for CEs?
Our mixed-methods study, conducted from September 2010 to March 2011, used two phases to triangulate the data. The study received ethics approval from the research ethics board of the Faculty of Health Sciences at McMaster University, in Hamilton, Ontario, Canada.
Phase 1: National focus groups
Adopting a constructivist approach, we developed a series of semistructured focus group questions derived from a review of the existing literature on CEs. We pilot-tested these questions on an expert panel of 10 CEs associated with the Royal College of Physicians and Surgeons of Canada, the national body that oversees medical specialist education in Canada. The pilot process involved two iterative rounds during June 2010: We presented the questions to the panel, whose members discussed the clarity of terms, the domains covered, and the scope of the associated prompts or probes. (These individuals did not participate in the study’s subsequent focus groups or national survey.) We conducted a thematic analysis of the transcribed responses to ensure that the structure of the focus group questions followed a consistent and comprehensive approach. The CE themes addressed in the final list of questions included the definition, the required competencies, the training process, and the process of support. (For the focus group questions, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A198).
In September 2010, we invited, via e-mail, all Canadian deans of medicine, associate deans of postgraduate and undergraduate medical education, and directors of centers for medical education or centers of medical education research (n = 65) to participate in the study’s focus groups. Each focus group included three to five participants and took place via teleconference call (led by J.S. or L.S.) during October or November 2010. The average length of the focus group sessions was 90 minutes.
We analyzed the transcripts of the audio-recorded focus group sessions using a grounded-theory approach.11–14 We conducted the analysis concurrently with data collection; two authors independently reviewed all transcripts (J.S. and L.S.). We continued to hold focus groups until saturation of themes was reached.
We used a constant comparative approach to identify themes and subthemes. In our final thematic analysis, we arrived by consensus at a list of domains of competence and competencies. We triangulated our findings through comparison with the results of our literature review and consultation with the content experts who piloted the focus group questions.
Phase 2: National needs assessment survey
Building on our analysis from phase 1, we developed a series of categorical survey questions that mapped to the domains of competence and competencies identified by the focus groups. A survey methodologist provided advice on the construction of the survey questions. We pilot-tested the survey using an expert panel of CEs associated with the Royal College of Physicians and Surgeons of Canada.
In February 2011, we invited all Canadian residency program directors (n = 727), academic/university department chairs (n = 302), and deans (including undergraduate, postgraduate, faculty development, and continuing professional development deans; n = 101) to participate in our Web-based survey. Using a modified Dillman15 method, we sent invitations by e-mail and followed up with e-mailed reminders at weeks 1, 2, and 4. There were eight main survey items that addressed topics such as the need for CEs, the domains of competence of a CE, and type of training required to become a CE. (For the survey questions, see Supplemental Digital Appendix 2, available at http://links.lww.com/ACADMED/A198.)
To prevent confusion with local definitions or misrepresentation based on established (and conflicting) concepts, we did not use the term clinician–educator in the survey. Rather, we used the term medical education consultant (or a variant) when required. The survey was available in both French and English.
We analyzed the survey responses using descriptive statistics.
Phase 1: Focus group results
A total of 22 individuals participated in five focus groups. The focus group participants consistently identified the following attributes as essential to CEs: (1) being active in clinical practice, (2) applying education theory to education practice, and (3) engaging in education scholarship. Each of these attributes is described in detail below.
Focus group participants did not consistently identify a particular administrative position (e.g., program director, department chair of education) as essential to the CE role.
Being active in clinical practice.
The vast majority of participants indicated that individuals who are to be called “clinician–educators” require an active clinical practice (as a physician or other health care professional) to have credibility and to help them translate theory into practice. In addition, participants noted that having a dual perspective, as both a practitioner and an educator, allows the CE to identify important and emerging questions in medical education. As typified by the following comment, participants viewed CEs as key role models for other clinicians who teach:
To move from being a clinician—as a core base of who this clinician–educator is—would be a mistake. I think that you would lose a valuable perspective and a valuable connection to the end users of whatever it is that you’re developing and putting into action. And it’s just not quite the same if you aren’t involved with the trainees.
A minority of participants, though, suggested that a clinical practice was not essential. In their view, basic science or social science educators could serve as CEs, provided they worked in collaboration with physicians:
I actually think that there are some amazing educators who do not come from a clinical background but who have a great deal of ability to provide very good support to [the] clinical environment … [W]e get too hung up on the medical expert role lots of times. There are many other aspects of patient care and being a physician that we can learn from[,] areas that are not clinically based … [Y]ou’re losing out on a whole wealth of opportunity for individuals with other skill sets to come in and participate in the education of physicians.
Applying education theory to education practice.
Most focus group participants viewed CEs as distinguished from other clinicians with teaching roles (i.e., “clinician–teachers”) by their application of education theory to teaching and learning:
So the clinical teacher is the one who is hands-on teaching, bedside … and once it moves into the scholarly realm, that becomes the educator.
There [are teachers] without … the educational understanding, the theory to support what they’re doing.
[CEs are] in that role as a consultant for … how to be an excellent teacher. And that goes along with the scholarly part, understanding the educational theory.
Engaging in education scholarship.
Finally, most focus group participants described the CE as someone who contributes to the evidence that informs the broad field of medical education. Some respondents narrowly defined this scholarship as education research in which a question is asked and an experiment or trial is performed to discover an answer. Others suggested a broader definition of scholarship, encompassing the public dissemination of an education innovation that builds on current evidence, theoretical frameworks, or best practices.
A clinician–educator is somebody who practices education and applies theory … [and] does research and tries to inform [education] theory based on their [clinical] practice.
A clinician–educator really means … someone who looks at new ways of doing things based on what’s happening [around] the globe, and looks for best practices, and incorporates those into new programs.
Refining CE competencies
The attributes that emerged from focus group discussions helped define a CE. The focus group responses also included specific CE competencies; these results and the responses about the training process informed the survey questions used in Phase 2 of our study. Thus, the survey served to validate the results of phase 1 of this study.
Phase 2: Survey results
A total of 350 individuals responded to the survey, for a response rate of 31% (350/1,130). Of the 350 respondents, 239 (68%) were program directors, 67 (19%) were academic department heads, and 44 (13%) were deans. All respondents had more than 5 years of clinical medical practice experience, and more than half (182; 52%) had been in clinical medical practice for more than 20 years; 10% (34) were no longer in clinical practice. The majority (283; 81%) practiced in an academic health center. Respondents’ medical education training included informal learning (14; 4%), faculty development (133; 38%), formal fellowship programs (84; 24%), master’s programs (67; 19%), and doctoral programs (35; 10%). All Canadian medical schools were represented; the greatest number of respondents were affiliated with McGill University, Université de Montréal, the University of Alberta, and the University of British Columbia.
The survey results showed a strong endorsement of the view that physicians with advanced training in medical education are needed to serve as educational consultants, with 85% (287/338) of respondents agreeing or strongly agreeing. More than 40% of respondents indicated that their training program would require the services of a CE* for at least one half-day per week (see Figure 1).
Survey participants were asked what level of clinical experience should be the minimum prerequisite for admission to a CE training program. Of the 284 respondents to this question, 82 (29%) indicated that only experienced clinicians should be eligible, whereas 99 (35%) considered physicians newly entered into practice to be eligible and 85 (30%) viewed senior residents as eligible. Only 17 respondents (6%) indicated that junior residents should be eligible.
Respondents’ ratings of 13 domains of competence for a CE are presented in Figure 2. The domains of competence endorsed by at least two-thirds of survey respondents as “very important” were communication skills (249; 89%), clinical teaching (221; 79%), assessment (218; 78%), curriculum development (191; 68%), program evaluation (190; 68%), and educational leadership (188; 67%). Domains of competence endorsed by 85% of respondents as “important” or “very important” included all except organizational/jurisdictional issues.
Finally, there was no clear endorsement for any particular training stream for CEs (see Figure 3). Among the survey respondents, 155 (55%) agreed or strongly agreed that a master’s degree in education is effective preparation, and 109 (39%) agreed or strongly agreed that faculty development programs are effective.
To our knowledge, this is the first study undertaken in a national context to support a formal definition of the CE role and its core competencies. The consensus that emerged from our focus group discussions and our survey is that a CE is a clinician active in health professional practice who applies theory to education practice, engages in education scholarship, and serves as a consultant to other health professionals on education questions and issues (see Figure 4). CE competencies arranged by common domains—as derived from existing literature, refined in our thematic analysis of focus group discussions, and validated as “important” or “very important” by more than 85% of respondents to our survey (see Figure 2)—are provided in Table 1.
The definition of clinician–educator that we propose here on the basis of our findings aligns with informal descriptions in the literature, such as the following:
Specialist medical educators have the expertise and commitment to lead and deliver evidence-based educational improvements, and to engage and motivate the many teaching clinicians.5
Perhaps the primary distinguishing characteristic of a clinician–educator is that they produce scholarship related to their educational activities.16
[D]octors employed by health service providers, [who] are primarily engaged in clinical practice, regularly teach, and have some or little involvement in research.8
Scholarship is an important component of the definition of clinician–educator, both to differentiate CEs from other clinicians in teaching roles and to help develop a legitimate academic identity for CEs.8 Scholarship is concerned with discovery (i.e., research) but also includes integration, application, and teaching.17 It advances best practices to aid learning, assessment, curriculum design, and other aspects of the broad field of health professions education.18 Building the evidentiary and theoretical base that informs health professions education is an essential task for CEs. However, this key element of the CE’s role is often threatened by competing demands arising from administrative responsibilities and education design.19 Research by Sheffield and colleagues20 suggests that CEs protect only 13% of their time for scholarship (not the minimum 20% in their job description) and that 43% of education scholarship occurs outside of the regular workweek.
The CE domains of competence and core competencies identified in this study map to those described in a survey of U.S. and Canadian medical schools on academic promotion criteria reported by Beasley and colleagues21 in 1997. The notable difference in the present study is that we found diminished emphasis on academic administration as a defining characteristic (only 36% of our survey respondents endorsed administration of educational programs as very important), suggesting that the role of the CE has been refined in the years since Beasley and colleagues’21 study. Although CEs may play a dual role and manage a program, education administration no longer defines the medical education consultant.
Finally, although our study demonstrated an 85% endorsement of the need for CEs, the process for training clinicians to meet this need was not clear. Neither graduate education nor faculty development programs were strongly supported by respondents. We believe this suggests that a hybrid approach of a formalized, rigorous program that applies theory to practice may be the most readily accepted instructional design. A 2010 study found that nearly 30% of U.S. medical schools have academies that support their teaching mission, and another 27% are planning or considering such academies.22 However, the primary mission of many of these academies is to increase the numbers and serve the needs of clinician–teachers, not CEs. Although nearly half of U.S. medical schools have medical education fellowships, Thompson and colleagues9 found the term to be broadly applied: The intensity and duration of such fellowships ranges from 10 hours in 1 month to 584 hours in 48 months. More rigorous and structured programs have a minimum duration of 1 year and cover education theory, teaching skills, assessment and evaluation, research methods, and educational leadership; they include a formal assessment of fellows and require the submission of independent scholarly projects.23–30 Such fellowships are sometimes aimed at residents at the end of their training or just after.
There are several limitations in our study. First, the response rate of 31% may suggest that the results are not representative of the population studied. However, this response rate is within one standard deviation of the mean for large surveys31 and reflects typical results of electronic surveys.32 We believe it is representative: The survey respondents were 350 individuals with diverse education backgrounds and positions across Canada. Although our response rate may have led to overendorsement of the need for CEs (i.e., nonresponders may not perceive the need), the validation of the definition and domains of competence of a CE would not necessarily be affected.
Second, because all respondents were from Canada, our results may not be generalizable to other countries. However, the 350 respondents made up a diverse population. They ranged from program directors to deans, and their medical education credentials ranged from informal training to doctoral studies. Every Canadian medical school (large, small, French-speaking, English-speaking) was represented in the responses. Although the medical education environment in Canada is informed by the CanMEDS framework,33 this framework has influenced medical education frameworks in 26 other jurisdictions around the world.34 Moreover, medical education systems in other countries are changing in response to societal demands for high-quality education, an increased need for practitioners, new standards, and innovative educational approaches. All of these factors imply that there is a need for clinicians trained as expert consultants and leaders in medical education. We therefore believe that our findings are broadly generalizable to the medical education community.
Finally, the broad endorsement of nearly all the CE domains of competence may suggest that the survey lacked discrimination. However, the survey items were developed on the basis of the grounded theory analysis of the focus group responses. This process permitted the refinement of the survey questions before the survey was distributed nationally. This mixed-methods approach facilitated an accurate analysis of the opinions of the survey population. It should be noted that all of the authors have graduate training in health professions education, which had the potential to bias the focus group analysis. However, the survey questions demonstrate that there was no evidence of bias (see Supplemental Digital Appendix 2 at http://links.lww.com/ACADMED/A198).
On the basis of a national study, we suggest a formal definition of a CE and describe the domains of competence and core competencies that inform CEs’ practice. Our findings demonstrate a need for CEs that may best be fulfilled by training through formalized programs. Health professions education leaders worldwide should consider developing cadres of CEs, who, as educational consultants, can help meet the challenges of 21st-century health professions education.
Acknowledgments: The authors wish to thank Curtis Lee, PhD, for his assistance with the deployment of their survey.
* The survey used the term medical education consultant rather than clinician–educator to ensure that respondents understood the academic role being studied and were not confused by local definitions of a CE. Cited Here...
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