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Integrating Clinician-Educators into Academic Medical Centers

Challenges and Potential Solutions

Levinson, Wendy, MD; Rubenstein, Arthur, MBBCh Guest Editors: THE COUNCIL OF ACADEMIC SOCIETIES TASK FORCE ON SCHOLARSHIP

SPECIAL THEME: Expanding the View of Scholarship: ARTICLES
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During the last decade academic medical centers (AMCs) have hired large numbers of clinician-educators to teach and provide clinical care. However, these clinician-educators often do not advance in academic rank, since excellence in clinical care and teaching alone is not adequate justification for advancement. The authors articulate the problems with the present system of recognition for clinician-educators—i.e., the requirement for regional and national reputation, the lack of reliable measures of clinical and teaching excellence, and the lack of training opportunities for young clinician-educators. They call for solutions, including fundamental changes in promotion criteria (e.g., focus criteria for promotion on clinician-educators' accomplishments within their institutions) and the development of valid and feasible methods to measure outcomes of teaching programs. Further, they recommend the development of a new faculty position, a “clinician-educator researcher,” to foster the scholarship of discovery in medical education and clinical practice. Investments in clinician-educator researchers will ultimately help AMCs to achieve their threefold mission—excellence in patient care, teaching, and research.

Dr. Levinson is professor of medicine at the University of Chicago Division of the Biological Sciences Pritzker School of Medicine, Chicago, Illinois; Dr. Rubenstein is the Gustave L. Levy Distinguished Professor, dean, and chief executive officer at Mount Sinai School of Medicine, New York University, New York, New York.

Correspondence and requests for reprints should be addressed to Dr. Levinson, Section of General Medicine, The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637; telephone: (773) 702-3045; fax: (773) 834-2238; e-mail: 〈wendy@medicine.bsd.uchicago.edu〉.

During the last decade academic medical centers (AMCs) have hired a large number of clinician-educators to teach and provide clinical care. However, these faculty often do not advance in academic rank, since excellence in clinical care and teaching alone is not adequate justification for advancement. In this article, we articulate the problems with the present system of recognition for clinician-educators and call for solutions, including fundamental changes in promotion criteria and the development of valid and feasible methods to measure outcomes of teaching programs. Further, we recommend the development of a new faculty position, a “clinician-educator researcher,” to foster the scholarship of discovery in medical education and clinical practice.

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BACKGROUND

The mission of AMCs is threefold: the provision of patient care; educating students, residents, fellows, and other health care professionals; and conducting research.1 Historically, AMCs have distinguished themselves from community-based medical centers by caring for patients with more complicated problems and by supporting educational endeavors as a primary goal; community hospitals are often more clinically focused. However, the most distinguishing characteristic of AMCs has been their commitment to research. For most AMCs, research has become the most important institutional mission. Their faculties have excelled in the discovery of new scientific knowledge. They have made remarkable contributions to the advancement of scientific understanding of diseases and to the development of new therapies, contributing to the marked increase in longevity of the population over the past century. Well-deserved national and international prestige and research funding have rewarded these accomplishments. Individual faculty members committed to research have been rewarded by promotion in academic rank and by tenure.

Patient care has also been an important aspect of the work of AMCs, but the research goal has had higher visibility. In the past, AMCs provided tertiary or quaternary care, often serving as consultants to community hospitals and their physicians for the most challenging patients or those that required highly sophisticated technologic care. Faculty at AMCs typically devoted a small percentage of their time to patient care (often about 20%) and the majority of time to research. In the early 1960s approximately 3% of the revenue of AMCs was derived from patient care activities, while the vast majority came from the support of research activities.2 Hence, patient care, while important, was a relatively minor part of the financing of AMCs; research was the driving force for the financial health of the institution.

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THE NEED TO REWARD CLINICIAN-EDUCATORS

The Problem

The situation described above has changed dramatically in the present economic environment. Clinical care is now critical for the financial viability of AMCs, with approximately 40–50% of their revenue derived from this aspect of their work.2 AMCs have developed networks of physicians and hospitals in order to enhance the referral of patients to their tertiary care services and support their own managed care plans. However, AMCs are often in competition for patients with community hospitals and affiliated physicians. Accordingly, AMCs are hiring many young full-time faculty members to meet the need for provision of clinical services; yet it is unclear how these clinician-educators should be integrated into the fabric of the AMC.3–5 For example, from 1986 to 1996 the department of medicine at the University of Chicago increased the number of clinician-educators from 20 to 73, while the number of research faculty members remained constant.4

Typically these clinician-educators devote the majority of their time caring for patients, teaching, and supervising students and residents in both inpatient and outpatient settings.4,6 Some clinician-educator faculty spend 50% of their time seeing patients and 50% teaching. These individuals play a leadership role in medical education, developing new curricula, administering major courses, and taking responsibility for evaluation of trainees. However, a larger percentage of these faculty spend the vast majority of their time (often 75–80%) seeing patients and devote a relatively small amount of time to supervising students, residents, and fellows. In primary care settings these faculty follow large panels of patients, often seeing 25–30 patients per day. Their responsibilities are time-consuming, since many hours are required to deliver and coordinate the primary and specialty care of these patients. Similarly, in surgical disciplines, the clinician-educator faculty are required to spend long hours in the operating room and additional time following the progress of postoperative patients. In addition to the sheer clinical demands, the clinician-educator job poses significant intellectual demands, since the “best clinicians” want and need to keep up to date with the rapidly expanding knowledge pertinent to their disciplines. Within institutions many of these faculty are often recognized by colleagues as superb clinicians, to whom they refer their family members for care. Since they focus their time and energy on clinical care, they invariably do it well. Yet, are they rewarded by their institutions for their clinical excellence?

In addition to meeting the clinical and intellectual demands mentioned above, these clinician-educator faculty are largely responsible for carrying out the critically important educational mission of the institution. Their teaching roles require not only a strong knowledge base, but also the ability to effectively educate students in a variety of settings, including teaching in the classroom, at the bedside in the hospital or nursing home, and in the busy outpatient clinic. As the clinical load and the time required for documentation of care increase, skilled clinician-educator faculty need to juggle the complex task of balancing patient care and the education of trainees. They are experts at integrating extensive clinical knowledge essential to the care of patients with complicated problems and communicating this knowledge and skill to their trainees. Accordingly, they are frequently recognized by students as the “best teachers,” often receiving awards and accolades. They are identified by residents as “role models.”7,8 Just as they support the clinical mission of AMCs, they are also the centerpieces of the teaching operation.

While clinician-educators excel at clinical care and teaching, they often are unable to devote time and energy to scholarship as defined by traditional academic criteria. Their responsibilities do not allow the hours necessary to develop and/or disseminate their creative educational products outside the institutions where they work. They rarely publish their novel educational programs in peer-reviewed journals, and they are infrequently asked to present their work at conferences outside their institutions. Furthermore, clinician-educator faculty are not usually trained in scientific methods; as a consequence they rarely conduct rigorous studies to objectively measure the effectiveness of their new educational programs. They infrequently publish research in the traditional academic peer-reviewed journals. Their work, however excellent, is often seen and appreciated only by their students, colleagues, and patients. But is it appreciated by the institution?

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Current Ways of Providing Rewards

Traditionally AMCs have rewarded faculty members by promotion and tenure. Many institutions have developed new tracks specifically for the clinician-educator faculty.9–13 These pathways use specific criteria to assess accomplishments in clinical care and teaching, rather than the criteria traditionally used to judge excellence in the research tracks. In a 1997 survey, 66 of 115 medical schools indicated that they had implemented separate promotion pathways or specific criteria for clinician-educator faculty.14 Yet these new tracks have not fully met the goal of rewarding clinician-educator faculty for their accomplishments. In most instances the criteria used to judge the achievements of these faculty for promotion are not consistent with their job responsibilities.3,5 There are three main problems with the present system for recognizing and developing CE faculty: the requirement for regional and national reputation, the lack of reliable and valid measurements of clinical and teaching accomplishments, and the lack of relevant training opportunities for clinician-educator faculty during their formative years to develop their scholarly skills in medical education.

The reputation requirement. Guidelines for promotion in CE tracks typically state that excellence in clinical care and excellence in teaching are essential but not sufficient for promotion to associate and full professor ranks.13–16 Rather, faculty members are required to demonstrate that they have regional and national reputations in their fields.17 Proponents of this requirement suggest that regional and national reputations attest to the excellence of these faculty members' scholarly contributions, since most often reputation depends on publication of scholarly work, including original articles, chapters, or books. In addition, letters from referees outside a faculty member's institution can be used to judge his or her reputation. In fact, we are often asked to write letters to support the promotion of clinician-educator faculty at institutions other than our own.

However, we have argued that the requirement for a regional and national reputation is not appropriate for these faculty.5 In fact, holding clinician-educator faculty to this standard may actually interfere with their primary goal of achieving excellence in patient care and teaching. The work of clinician-educator faculty requires a dedicated focus on meeting the needs of patients and students. Excellence in those endeavors requires the faculty members to be available not only during the day, but also at night and weekends to meet urgent needs. These obligations are extraordinarily time-consuming. When a clinician-educator acts as attending physician on an inpatient ward, he or she finds it extremely difficult to devote significant time and attention to any substantive administrative or scholarly activities. Furthermore, time away from the institution is difficult to arrange because of the need to be constantly available for patients' needs. Frequent travel to scientific meetings to present academic work, an important prerequisite for establishing a reputation outside a clinician-educator's own institution, is not a realistic expectation when clinical and teaching activities cannot be compromised.

Lack of valid measurements. Second, while many institutions have made efforts to develop new criteria to judge clinical and teaching excellence, objective measurement of excellence in these areas is a challenging task.18 In the teaching domain, excellence is most often measured by ratings of students and receipt of teaching awards, but these approaches have limitations.19–24 In particular, the most popular teachers may not be the ones who give students important but sometimes critical feedback. Other outcome measures of effective teaching, such as changes in the knowledge, skills, and attitudes of the learners, are not well developed. Peer review of teaching excellence has been proposed, but is difficult to implement due to the time required and lack of standards for assessment.25

Similarly, measuring the quality of clinical care is problematic. While most faculty members can recommend a “good” primary care doctor or specialist, they are hardpressed to articulate specific observable characteristics that form the basis for that judgment. Promotion and tenure committees have a paucity of objective measurements of clinical excellence, and thus it is difficult to evaluate the clinician-educator faculty for their accomplishments.25 The old adage “If you can't count it, it doesn't count” applies in this context.

Lack of training opportunities. Third, there is a lack of training opportunities to help clinician-educator faculty develop their scholarly skills in the field of medical education. Traditionally, AMCs have recognized that junior faculty members developing careers in research need explicit support and time to become successful. This support has included protected time uninterrupted by clinical and teaching responsibilities, mentorship from senior research faculty, space, and a financial commitment. It has also included support from mentors and administrators to help young researchers write, submit, and manage research grants. Junior research faculty in AMCs have a clear road map indicating the pathway to success. Furthermore, institutional support has been supplemented by federal and private-sector programs for junior faculty career development. In contrast, clinician-educator faculty lack access to these resources, which they need to become successful leaders in their fields. Young faculty members planning careers in medical education require training in curricular development, techniques to analyze and improve their teaching approaches, and research skills to study a variety of issues related to educational programs. Faculty development programs both regionally and nationally have started to provide training for clinician-educators.26,27 For example, at Stanford Medical School, Skeff and colleagues have implemented a national program designed to enhance the teaching skills of clinician-educator faculty and “train the trainers,” who can disseminate these skills to colleagues at their home institutions.28 Other AMCs have started similar faculty development programs locally, but in general, these are in their early stages of development. The federal government has supported faculty development efforts with grants to internal medicine, family medicine, and pediatrics departments. Despite these early steps, developing the faculty leaders in medical education remains a challenging task for AMCs in this decade.

In sum, clinician-educator faculty are hired to provide high-quality patient care and to teach, yet excellence at these endeavors is hard to prove with existing methods and may not be adequate for advancement. How can excellent scholarship—which is a path to advancement—be fostered for clinician-educators? In the next section, we propose a way.

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OPTIONS FOR SUPPORTING CLINICIAN-EDUCATORS IN AMCS

Academic medical centers that seek excellence in clinical care, teaching, and research have several options in managing their growing numbers of clinician-educator faculty. We see two possible approaches, which are not mutually exclusive. These are (1) viewing clinician-educator faculty as short-term employees and (2) developing a cadre of long-term clinician-educator faculty. The latter option will be informed and enhanced by creating a new position, a “clinician-educator researcher.”

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Hiring Clinician-Educators as Short-term Employees

Some prestigious AMCs have recruited clinician-educator faculty to meet the service role of clinical care and teaching for up to seven years, the usual time period permitted for those with the rank of assistant professor. Since these faculty are unlikely to meet the institution's criteria for scholarship required for promotion to associate professor, they typically leave the institution after six or seven years. In turn they are replaced with a new group of clinician-educator faculty. This strategy meets the institution's need for a large work-force of clinician-educators, but has the disadvantage of precluding the development of clinician-educator leaders in medical education or the fostering of the maturation of seasoned clinicians in the full-time track system. It also has a profoundly negative effect on faculty morale, as mid-level clinician-educators seek jobs elsewhere with the anticipation of not being promoted, and junior faculty realize that their positions are only temporary. The institution develops a reputation of not being a desirable place for the “best and brightest” young physicians planning careers as clinician-educators.

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Developing a Cadre of Long-term Clinician-Educator Faculty

Academic medical centers have taken steps toward changing their promotion systems by establishing new tracks, modifying promotion criteria, and introducing “teaching portfolios” to facilitate the evaluation of clinician-educators.21,29 While laudatory, these measures often fall short of meeting the goal of rewarding and supporting clinician-educator faculty. We have previously argued that these individuals are critical to the mission of AMCs.5 However, to successfully integrate them into the fabric of the AMC will require fundamental changes in the promotion process. Specifically, we have suggested that the requirements for a regional and national reputation and reliance on publications as a measure of success should be eliminated.5 The responsibilities of a clinician-educator faculty member should focus internally in that individual's institution. These responsibilities require a full-time commitment and allow little time for activities that would result in a reputation outside the institution. In fact, the faculty member's reputation inside the institution should be the ultimate measure of his or her success. Evaluations by trainers and peers should weigh heavily in decisions about promotion and should depend on accomplishments within the institution. The requirement for publication should be replaced by new objective methods of evaluating excellence in teaching and clinical care. These methods are presently being developed, but a great deal more work is needed to create feasible, reliable, and broadly accepted tools. The changes we have described are necessary to support the present clinician-educator faculty, who form the backbone of AMCs' clinical and teaching enterprises. Appropriate recognition will ensure that excellent faculty choose to dedicate themselves to these roles.

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Creating a New Position: “The Clinician-Educator Researcher”

In addition to finding ways to recognize excellence in teaching and clinical care, it is absolutely necessary to develop talent and devote resources to foster scholarship in the field of medical education and clinical practice. This may best be carried out by creating a new position called a “clinician-educator researcher.”

Institutions need to invest substantially in the “scholarship of discovery” concerning clinical care and education, as they did in the scholarship of discovery concerning biomedicine and related fields during the last 50 years. AMCs should recognize that the “basic science” of clinical care and education requires an intellectual commitment to discovery. For example, basic research must be conducted to produce valid, reliable, and feasible methods to measure the quality of teaching and the outcomes of educational programs.23 Better tools are needed to evaluate students' performances and to provide them with constructive feedback. New and innovative educational techniques must be developed to teach using computer-based methods. Broadly, the field of medical education requires a major investment in research. This investment includes several key components to allow clinician-educators to carry out such research.

First, physicians should receive advanced master's-level or PhD-level training in the area of education. This sophisticated level of training is needed to conduct “basic research,” drawing on expertise that is already established in schools of education but, heretofore, rarely applied to medical education. At present, the number of MD-PhD trained individuals who have made major contributions to this field is very small. We need more physicians with rigorous training and expertise to provide leadership in research related to medical education.

Subsequent to such training, AMCs will need to support these faculty members, who will need to devote more than 75% of their effort to research endeavors concerning education or clinical care, similar to the effort of faculty conducting basic biomedical research. Junior faculty members will need financial support and mentorship in their early faculty years. Ultimately, they will form a critical mass of individuals doing the “scholarship of discovery” in medical education and clinical care.

Third, this vision will require the commitment of local, regional, and federal funding to provide financial support in the form of junior faculty development awards and RO1-type funding mechanisms for research in medical education or clinical care. Furthermore, this investment will need to be sustained over time to achieve a level of excellence similar to that achieved by AMCs in biomedical research.

In our own settings we have seen faculty members who clearly could be engaged in this kind of scholarship, particularly research in education, and who need the kinds of support and training mentioned earlier to successfully pursue such scholarship. They are exceedingly creative. They have implemented novel approaches to teaching traditional areas of the curriculum, such as anatomy, and important but often neglected subjects, such as cross-cultural medicine. In these cases, the faculty members took the initiative to create the new programs without significant institutional resources. Usually these faculty develop the innovations in their own time after completing their regular obligations and with little institutional support. Typically, as the program develops a reputation within the institution, the faculty member is able to garner modest support from the medical school or hospital to continue or expand it. Often, however, the faculty member does not have the rigorous research knowledge or writing experience to study the program and disseminate information about it outside the institution.

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Two Examples

For example, at the University of Chicago, a clinician-educator faculty member developed a novel program designed to teach medical students communication skills with patients from different cultures. The program allowed students an opportunity to practice communication with standardized patients from different ethnic and racial minority groups. In each case, the standardized patient presented a communication barrier based on cultural beliefs or customs that physicians might not discover without specific communication skills. The students and faculty judged the program to be highly successful, but evaluations were limited to self-ratings of communication skills before and after the program.

While other medical schools could benefit by learning about this cross-cultural curriculum, the faculty member who designed the course is inexperienced at writing manuscripts for publication. There are few journals that publish articles in the field of medical education, especially as the objective evaluation of their effectiveness is often an issue in the review process. (The Journal of General Internal Medicine recently introduced a new format called “Innovations in Medical Education,” designed to help disseminate information about these types of educational programs in internal medicine.30 Also, Academic Medicine has for several years published its annual “In Progress” feature of short reports of innovative but often fledgling programs in all areas of medical education.) The University of Chicago faculty member, like other bright young clinician-educator faculty, has the creativity to address an important educational problem in an innovative fashion, but needs the skills in program evaluation and writing to be able to communicate her work to the medical community at large.

A second example involves an outstanding teacher of gross anatomy at Mount Sinai School of Medicine. He has developed a unique course, which has as its distinguishing feature the active participation of faculty from 15 different basic and clinical departments, including a number of chairs and volunteer faculty. This interdisciplinary approach brings to the students, from the very beginning, direct one-on-one encounters or presentations by the most outstanding physicians and surgeons, as well as by the core anatomy medical faculty. The presence of many student teaching assistants, drawn from senior student ranks and advanced graduate students, adds an additional vibrant dimension. This mixture of teachers is present throughout the course, and establishes in the students' minds the immediate applicability of what they are learning. (No one ever asks, “Why do we have to know this?”)

In addition, this course has also been a leader in melding dissection with extraordinary opportunities made possible by advances in technology, literally providing new ways to see the body. For example, this course augments teaching of the anatomy of portions of the body by minimally invasive approaches, such as laparoscopy. Indeed, the surgeons give presentations on this technique and also bring laparoscopes to the laboratory to reveal examples of anatomy directly. Similarly, the advent of new imaging modalities has enabled the faculty to introduce an array of new ways to visualize multidimensional forms, including three-dimensional visualization of the orbit and eye, ultrasound imaging of the prostate, three-dimensional computerized tomographic images of the paranasal sinuses, and multiplanar magnetic resonance imaging of the limbs. Yet, this creative educator does not necessarily have the opportunity to present his innovative course at national meetings or to publish it in respected peer-reviewed journals.

We offer these two examples to illustrate the potentially rich opportunities available in the field of medical education and medical education research. AMCs should choose to invest in faculty committed to research in medical education and clinical care. Ultimately, a long-term investment will ensure that AMCs achieve in education the superb levels of scientific scholarship that they have attained in basic medical research.

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RECOMMENDATIONS

As they have for years in biomedical research, it is time for AMCs to confirm their commitment to excellence in patient care and education, including the scholarship that goes with these activities. Clinician-educators should continue to commit their full energies and intellects to being the best clinicians and teachers possible to carry out the mission of these institutions. However, AMCs must develop more objective and innovative ways to evaluate the accomplishments of these important faculty. We thus call for the development of a new cadre of clinician-educators, who presently do not exist in most institutions. These individuals, with appropriate support and training, will develop the scholarship of medical education and clinical care. In turn, the scholarship will make it possible to objectively evaluate clinician-educators who devote most of their time to patient care and teaching. All this will also ensure the leadership of AMCs in creatively developing and supporting the fields of medical education and clinical care in ways that traditionally have been most emphasized for biomedical research.

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